Provider Demographics
NPI:1255603593
Name:SMOLAK-KETTLEHAKE, REBECCA ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ANN
Last Name:SMOLAK-KETTLEHAKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BIDDLE AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3982
Mailing Address - Country:US
Mailing Address - Phone:302-261-6901
Mailing Address - Fax:302-365-6072
Practice Address - Street 1:200 BIDDLE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-3968
Practice Address - Country:US
Practice Address - Phone:302-261-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2024-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05020103T00000X
DEB1-0000893103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist