Provider Demographics
NPI:1285373340
Name:BINGHAM, REBECKA DAWN
Entity type:Individual
Prefix:
First Name:REBECKA
Middle Name:DAWN
Last Name:BINGHAM
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 1:130 N 1700 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5035
Mailing Address - Country:US
Mailing Address - Phone:801-830-0694
Mailing Address - Fax:
Practice Address - Street 1:9361 S 300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2902
Practice Address - Country:US
Practice Address - Phone:801-826-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool