Provider Demographics
NPI:1255689964
Name:ELLIOTT, REBECCA RUEANNE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RUEANNE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 ROSS RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5558
Mailing Address - Country:US
Mailing Address - Phone:580-306-5557
Mailing Address - Fax:
Practice Address - Street 1:608 HIGHWAY 271 N
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2055
Practice Address - Country:US
Practice Address - Phone:580-298-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid