Provider Demographics
NPI:1215400460
Name:MATHERLY, REBECCA A
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:MATHERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BOHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0614
Mailing Address - Country:US
Mailing Address - Phone:270-886-2205
Mailing Address - Fax:270-886-0392
Practice Address - Street 1:607 HAMMOND PLZ
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4971
Practice Address - Country:US
Practice Address - Phone:270-881-9551
Practice Address - Fax:270-885-5871
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
KY2546291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator