Provider Demographics
NPI:1164757134
Name:ALLEN, REBECCA HATHAWAY (LSAA)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:HATHAWAY
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 ISLETA BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6658
Mailing Address - Country:US
Mailing Address - Phone:505-873-2761
Mailing Address - Fax:505-873-2819
Practice Address - Street 1:6000 ISLETA BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6658
Practice Address - Country:US
Practice Address - Phone:505-873-2761
Practice Address - Fax:505-873-2819
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0074461101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)