Provider Demographics
NPI:1780268672
Name:SIWANOWICZ, REBECCA JYLL (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JYLL
Last Name:SIWANOWICZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 NC 87 S
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-0212
Mailing Address - Country:US
Mailing Address - Phone:954-235-7013
Mailing Address - Fax:
Practice Address - Street 1:284 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1831
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW169611041C0700X
NCC0162561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical