Provider Demographics
NPI:1588397558
Name:PHOSAVATH, REBECCA A
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:PHOSAVATH
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 1:109 TALLOW RD
Mailing Address - Street 2:
Mailing Address - City:POMONA PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32181-2462
Mailing Address - Country:US
Mailing Address - Phone:386-546-5944
Mailing Address - Fax:
Practice Address - Street 1:109 TALLOW RD
Practice Address - Street 2:
Practice Address - City:POMONA PARK
Practice Address - State:FL
Practice Address - Zip Code:32181-2462
Practice Address - Country:US
Practice Address - Phone:386-546-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-223696106S00000X
FL1-24-76116103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician