Provider Demographics
NPI:1518384148
Name:PETTY, REBECCA MARIE (MA INTERN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:PETTY
Suffix:
Gender:F
Credentials:MA INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5055
Mailing Address - Country:US
Mailing Address - Phone:360-676-2164
Mailing Address - Fax:360-676-2144
Practice Address - Street 1:614 PETERSON RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-2606
Practice Address - Country:US
Practice Address - Phone:360-676-2164
Practice Address - Fax:360-676-2144
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60583009101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor