Provider Demographics
NPI:1740897248
Name:GOLD, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GOLD
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 1:3701 LAKE ONTARIO DR APT 205
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-6748
Mailing Address - Country:US
Mailing Address - Phone:219-508-8805
Mailing Address - Fax:
Practice Address - Street 1:1308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2719
Practice Address - Country:US
Practice Address - Phone:219-281-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000800A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health