Provider Demographics
NPI:1487223079
Name:RIDELLA, REBECCA LYNN (LCMHC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:RIDELLA
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 VT ROUTE 109
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05492-9546
Mailing Address - Country:US
Mailing Address - Phone:802-521-5550
Mailing Address - Fax:
Practice Address - Street 1:3414 VT ROUTE 109
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:VT
Practice Address - Zip Code:05492-9546
Practice Address - Country:US
Practice Address - Phone:802-521-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0065893101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty