Provider Demographics
NPI:1144866419
Name:SHOUP, REBEKAH CONLISK (LPCA)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:CONLISK
Last Name:SHOUP
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27249-3346
Mailing Address - Country:US
Mailing Address - Phone:704-493-8665
Mailing Address - Fax:
Practice Address - Street 1:8007 N POINT BLVD STE 209
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3268
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:866-338-5921
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15319101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health