Provider Demographics
NPI:1306299771
Name:SO, REBEKAH
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:SO
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 1:101 N INDIAN HILL BLVD STE C1-200
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4667
Mailing Address - Country:US
Mailing Address - Phone:909-333-7434
Mailing Address - Fax:909-503-0603
Practice Address - Street 1:101 N INDIAN HILL BLVD STE C1-200
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4667
Practice Address - Country:US
Practice Address - Phone:909-333-7434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical