Provider Demographics
NPI:1124293824
Name:WEISENTHAL, REBECCA GAIL
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:GAIL
Last Name:WEISENTHAL
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 1:1923 J N PEASE PL STE 104
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4534
Mailing Address - Country:US
Mailing Address - Phone:704-604-2325
Mailing Address - Fax:
Practice Address - Street 1:1923 J N PEASE PL STE 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4534
Practice Address - Country:US
Practice Address - Phone:704-604-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3026103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist