Provider Demographics
NPI:1669748356
Name:MORLEY, REBECCA JO (MA)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JO
Last Name:MORLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JO
Other - Last Name:LACKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:1412 ROYAL PALM SQUARE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1075
Mailing Address - Country:US
Mailing Address - Phone:239-560-7202
Mailing Address - Fax:
Practice Address - Street 1:1412 ROYAL PALM SQUARE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1075
Practice Address - Country:US
Practice Address - Phone:239-560-7202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6264101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47-5202613OtherEIN