Provider Demographics
NPI:1457197493
Name:CARSON, REBECCA (PCLC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SW HIGGINS AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1489
Mailing Address - Country:US
Mailing Address - Phone:406-214-4810
Mailing Address - Fax:
Practice Address - Street 1:700 SW HIGGINS AVE STE 107
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1489
Practice Address - Country:US
Practice Address - Phone:406-214-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-71911101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor