Provider Demographics
NPI:1730774175
Name:SMITH, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SMITH
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 1:93 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-1764
Mailing Address - Country:US
Mailing Address - Phone:304-840-6032
Mailing Address - Fax:
Practice Address - Street 1:73 LAUREL LICK RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-7517
Practice Address - Country:US
Practice Address - Phone:304-840-6032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker