Provider Demographics
NPI:1417758962
Name:CLARK, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 S 7TH ST APT 10F
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76706-2401
Mailing Address - Country:US
Mailing Address - Phone:936-645-8269
Mailing Address - Fax:
Practice Address - Street 1:1818 S 7TH ST APT 10F
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-2401
Practice Address - Country:US
Practice Address - Phone:936-645-8269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker