Provider Demographics
NPI:1154814085
Name:MANDEVILLE, REBECCA CONSTANCE (MFT / MFC# 43860)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CONSTANCE
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:MFT / MFC# 43860
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 HIGHWAY 101 # 228
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-7634
Mailing Address - Country:US
Mailing Address - Phone:650-575-9151
Mailing Address - Fax:
Practice Address - Street 1:17015 QUAIL RIDGE RD
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:CA
Practice Address - Zip Code:96022-9056
Practice Address - Country:US
Practice Address - Phone:650-575-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health