Basic Information
| Provider Information | |||||||||
| NPI: | 1962479568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAW | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286409723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362464542 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286409723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362464542 | ||||||||
| FaxNumber: | 8282625687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 4103 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 135HJ | 01 | NC | BCBS OF NC | OTHER | C0916 | 01 | NC | MEDCOST | OTHER | N/A | 01 | NC | CBHA | OTHER | 2177617 | 01 | NC | CIGNA BEHAVIORAL HEALTH | OTHER | 6102748 | 05 | NC | MEDICAID |