Provider Demographics
NPI:1568691400
Name:EDEN, REBECCA JO (ISC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:EDEN
Suffix:
Gender:F
Credentials:ISC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 DESERT HILLS CIR APT 49
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-6607
Mailing Address - Country:US
Mailing Address - Phone:307-689-6459
Mailing Address - Fax:
Practice Address - Street 1:1001 DESERT HILLS CIR APT 49
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-6607
Practice Address - Country:US
Practice Address - Phone:307-689-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY104790-753171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator