Provider Demographics
NPI:1518574011
Name:ROTH, REBECCA LEE-WON (SUDP/T)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE-WON
Last Name:ROTH
Suffix:
Gender:F
Credentials:SUDP/T
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:KRAUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5721 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-3132
Mailing Address - Country:US
Mailing Address - Phone:715-529-1250
Mailing Address - Fax:
Practice Address - Street 1:661 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4300
Practice Address - Country:US
Practice Address - Phone:360-337-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60700333101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)