Provider Demographics
NPI:1255821815
Name:WILLARD, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WILLARD
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 1:11202 NW 114TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8780
Mailing Address - Country:US
Mailing Address - Phone:405-537-0059
Mailing Address - Fax:
Practice Address - Street 1:11202 NW 114TH ST
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-8780
Practice Address - Country:US
Practice Address - Phone:405-537-0059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional