Provider Demographics
NPI:1104600592
Name:WELBORN, REBECCA J (LACA, BSADC,CAPRC II)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:J
Last Name:WELBORN
Suffix:
Gender:F
Credentials:LACA, BSADC,CAPRC II
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:WELBORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LACA, BSADC,CAPRC II
Mailing Address - Street 1:304 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KNIGHTSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46148-1326
Mailing Address - Country:US
Mailing Address - Phone:317-318-4802
Mailing Address - Fax:
Practice Address - Street 1:704 N STATE ST STE A
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-3616
Practice Address - Country:US
Practice Address - Phone:317-406-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN172V00000X
INCAPRC2-5198175T00000X
IN99128120A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist