Provider Demographics
NPI:1649876566
Name:REBEL GOAT FARM,INC
Entity type:Organization
Organization Name:REBEL GOAT FARM,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR AND CO-FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:WAHLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-241-3273
Mailing Address - Street 1:250 MILLIONAIRE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-8251
Mailing Address - Country:US
Mailing Address - Phone:910-241-3273
Mailing Address - Fax:
Practice Address - Street 1:250 MILLIONAIRE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384-8251
Practice Address - Country:US
Practice Address - Phone:910-241-3273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty