Provider Demographics
NPI:1467619239
Name:WILLARD, REBECCA SUE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:SUE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:S
Other - Last Name:WILLARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3930 8TH ST. SOUTH SUITE 101
Mailing Address - Street 2:CHILD & ADOLESCENT PSYCHIATRY CONSULTANTS (BEHREND PSYC
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494
Mailing Address - Country:US
Mailing Address - Phone:715-423-2030
Mailing Address - Fax:715-423-2032
Practice Address - Street 1:3930 8TH ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6511
Practice Address - Country:US
Practice Address - Phone:715-423-2030
Practice Address - Fax:715-423-2032
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6637-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39771800Medicaid