Provider Demographics
NPI:1497134100
Name:REBECCA SMOLAK-KETTLEHAKE PSY D LLC
Entity Type:Organization
Organization Name:REBECCA SMOLAK-KETTLEHAKE PSY D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMOLAK-KETTLEHAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:302-261-6901
Mailing Address - Street 1:200 BIDDLE AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3968
Mailing Address - Country:US
Mailing Address - Phone:302-261-6901
Mailing Address - Fax:302-365-6072
Practice Address - Street 1:200 BIDDLE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3968
Practice Address - Country:US
Practice Address - Phone:302-261-6901
Practice Address - Fax:302-365-6072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty