Provider Demographics
NPI:1508133752
Name:BACON, REBECCA CORALYN (APC)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:CORALYN
Last Name:BACON
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 S STATE ST
Mailing Address - Street 2:STE 160
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1061
Mailing Address - Country:US
Mailing Address - Phone:801-773-2044
Mailing Address - Fax:801-773-4826
Practice Address - Street 1:189 S STATE ST
Practice Address - Street 2:STE 160
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1061
Practice Address - Country:US
Practice Address - Phone:801-773-2044
Practice Address - Fax:801-773-4826
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT78488768-6009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional