Provider Demographics
NPI:1518241876
Name:HUSTAD, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HUSTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 BROADWAY ST N STE 114B
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-4728
Mailing Address - Country:US
Mailing Address - Phone:715-308-5742
Mailing Address - Fax:888-972-4831
Practice Address - Street 1:1421 BROADWAY ST N STE 114B
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-4728
Practice Address - Country:US
Practice Address - Phone:715-308-5742
Practice Address - Fax:888-972-4831
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2072106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist