Provider Demographics
NPI:1528536083
Name:REID, REBECCA MARTINEZ (PHD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARTINEZ
Last Name:REID
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 E WOODSTOCK PL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6180
Mailing Address - Country:US
Mailing Address - Phone:812-219-5867
Mailing Address - Fax:
Practice Address - Street 1:2201 E WOODSTOCK PL
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6180
Practice Address - Country:US
Practice Address - Phone:812-219-5867
Practice Address - Fax:812-219-5867
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043208A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty