Provider Demographics
NPI:1386844546
Name:SIDWELL-DOUGLAS, REBECCA LYNN
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LYNN
Last Name:SIDWELL-DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:SIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:14377 WOODLAKE DR
Mailing Address - Street 2:SUITE 308
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5735
Mailing Address - Country:US
Mailing Address - Phone:314-576-6493
Mailing Address - Fax:314-576-7319
Practice Address - Street 1:14377 WOODLAKE DR
Practice Address - Street 2:SUITE 308
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5735
Practice Address - Country:US
Practice Address - Phone:314-576-6493
Practice Address - Fax:314-576-7319
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028054101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor