Basic Information
Provider Information | |||||||||
NPI: | 1164859492 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DARK | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | NOEL | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CMT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DARK | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | NOEL | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2707 AMBERWOOD LN | ||||||||
Address2: |   | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950652002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606099539 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 411 E LAKE AVE | ||||||||
Address2: |   | ||||||||
City: | WATSONVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 950764424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8317286445 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2013 | ||||||||
LastUpdateDate: | 03/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X |   |   | N |   | Behavioral Health & Social Service Providers | Psychologist | Counseling | 225700000X | MA60377068 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
No ID Information.