Provider Demographics
NPI:1619795473
Name:MARTIN, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MARTIN
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 1:1655 43RD ST S STE 205
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3583
Mailing Address - Country:US
Mailing Address - Phone:701-793-0798
Mailing Address - Fax:
Practice Address - Street 1:1635 43RD ST S STE 105
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3579
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional