Provider Demographics
NPI:1659755304
Name:WISTERMAN, REBEKAH
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:WISTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:REBEKAH
Other - Middle Name:WISTERMAN
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:905 DEVILLE LN
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-6313
Mailing Address - Country:US
Mailing Address - Phone:318-242-4622
Mailing Address - Fax:
Practice Address - Street 1:905 DEVILLE LN
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6313
Practice Address - Country:US
Practice Address - Phone:318-242-4622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional