Provider Demographics
NPI:1295922482
Name:LOCKWOOD, REBECCA L (PHD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 COVENTRY LN
Mailing Address - Street 2:SUITE 103A
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7504
Mailing Address - Country:US
Mailing Address - Phone:847-754-1488
Mailing Address - Fax:815-356-1488
Practice Address - Street 1:453 COVENTRY LN
Practice Address - Street 2:SUITE 103A
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7504
Practice Address - Country:US
Practice Address - Phone:847-754-1488
Practice Address - Fax:815-356-1488
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212802Medicare UPIN