Provider Demographics
NPI:1518036763
Name:BLACK, REBECCA M (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:B
Other - Last Name:MAYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9 HANOVER ST
Mailing Address - Street 2:SUITE 2 WEST CENTRAL SERVICES INC
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:603-448-6001
Practice Address - Street 1:20 WEST PARK ST
Practice Address - Street 2:SUITES 416 AND 219
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-448-1101
Practice Address - Fax:603-448-8249
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH362103T00000X
VT0480000202103T00000X
MA472103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist