Provider Demographics
NPI:1609483320
Name:WYSOSKI, REBECCA J (LAC, PCLC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:WYSOSKI
Suffix:
Gender:F
Credentials:LAC, PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-2550
Mailing Address - Country:US
Mailing Address - Phone:406-586-5493
Mailing Address - Fax:406-587-1238
Practice Address - Street 1:2310 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2550
Practice Address - Country:US
Practice Address - Phone:406-586-5493
Practice Address - Fax:406-586-5493
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25573101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)