Provider Demographics
NPI:1801060504
Name:LEACOCK, REBECCA MARY (MFT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARY
Last Name:LEACOCK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 JEANNETTE PRANDI WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903
Mailing Address - Country:US
Mailing Address - Phone:415-507-2926
Mailing Address - Fax:415-499-6978
Practice Address - Street 1:4 JEANNETTE PRANDI WAY
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1133
Practice Address - Country:US
Practice Address - Phone:415-507-2926
Practice Address - Fax:415-499-6978
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health