Provider Demographics
NPI:1164859492
Name:DARK, REBECCA NOEL (CMT)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:NOEL
Last Name:DARK
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:NOEL
Other - Last Name:DARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:106H00000X
Mailing Address - Street 1:216 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4747
Mailing Address - Country:US
Mailing Address - Phone:360-609-9539
Mailing Address - Fax:
Practice Address - Street 1:411 E LAKE AVE
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4424
Practice Address - Country:US
Practice Address - Phone:831-728-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2023-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
WAMA60377068225700000X
CAAMFT139158106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
46-2426846Other106H00000X