Provider Demographics
NPI:1679648638
Name:HARDY, REBECCA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4841
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4841
Mailing Address - Country:US
Mailing Address - Phone:208-904-1573
Mailing Address - Fax:208-904-1583
Practice Address - Street 1:1257 EAST CENTER STREET
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-1257
Practice Address - Country:US
Practice Address - Phone:208-904-1583
Practice Address - Fax:208-904-1583
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME40101YA0400X
ME6661041C0700X
ID321141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
005062OtherVALUE OPTIONS
5722229OtherAETNA
1036664OtherCIGNA
ME010826OtherANTHEM
1036664OtherCIGNA
ME010826OtherANTHEM