Provider Demographics
NPI:1861815763
Name:MCCONNELL, REBECCA L (AA, BA, MA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:AA, BA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3240
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-1240
Mailing Address - Country:US
Mailing Address - Phone:408-444-1303
Mailing Address - Fax:
Practice Address - Street 1:2512 SAMARITAN CT
Practice Address - Street 2:SUITE I
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4002
Practice Address - Country:US
Practice Address - Phone:408-444-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52134101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional