Provider Demographics
NPI:1861016776
Name:BOUCHILLON, REBECCA LYNN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:BOUCHILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 CYPRESS CREST TER
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-6624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 N MIDWAY DR
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-2708
Practice Address - Country:US
Practice Address - Phone:760-291-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist