Provider Demographics
NPI:1407014459
Name:BARDWELL, REBEKAH ALIZAH (MED, LMHC)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:ALIZAH
Last Name:BARDWELL
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 MIDDLE RIVER DR
Mailing Address - Street 2:STE. 307
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3544
Mailing Address - Country:US
Mailing Address - Phone:561-504-4373
Mailing Address - Fax:954-566-1186
Practice Address - Street 1:915 MIDDLE RIVER DR
Practice Address - Street 2:STE. 307
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3544
Practice Address - Country:US
Practice Address - Phone:561-504-4373
Practice Address - Fax:954-566-1186
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9246101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health