Provider Demographics
NPI:1689395378
Name:WHITE, REBECCA DENISE (CPRC, CPSS, CPRC SUP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DENISE
Last Name:WHITE
Suffix:
Gender:F
Credentials:CPRC, CPSS, CPRC SUP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 E 1340 S
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-1248
Mailing Address - Country:US
Mailing Address - Phone:208-505-9990
Mailing Address - Fax:
Practice Address - Street 1:492 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4541
Practice Address - Country:US
Practice Address - Phone:208-206-2285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist