Provider Demographics
NPI:1508238924
Name:STAFFORD, REBECCA (MA, CRC, RBT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MA, CRC, RBT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:GOODSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8282 28TH CT NE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-7162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8282 28TH CT NE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-7162
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-25
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WA00229977103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation