Provider Demographics
NPI:1497380190
Name:KING, REBECCA ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-0446
Mailing Address - Country:US
Mailing Address - Phone:801-718-3987
Mailing Address - Fax:
Practice Address - Street 1:225 STONEHENGE CIR
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9200
Practice Address - Country:US
Practice Address - Phone:801-718-3987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT34429135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty