Provider Demographics
NPI:1104053230
Name:WILSEY, REBECCA LEE (LSW)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LEE
Last Name:WILSEY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 W EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7701
Mailing Address - Country:US
Mailing Address - Phone:208-409-2751
Mailing Address - Fax:
Practice Address - Street 1:740 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6420
Practice Address - Country:US
Practice Address - Phone:208-343-7797
Practice Address - Fax:208-343-0064
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-29817104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker