Provider Demographics
NPI:1649752437
Name:LACQUE, REBECCA ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:LACQUE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 WALL ST STE 13
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7800
Mailing Address - Country:US
Mailing Address - Phone:530-521-4470
Mailing Address - Fax:
Practice Address - Street 1:315 WALL ST STE 13
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-7800
Practice Address - Country:US
Practice Address - Phone:530-521-4470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05Medicaid