Provider Demographics
NPI:1588983894
Name:DE VRIES, REBECCA SUE (PHD, MA, MED)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:DE VRIES
Suffix:
Gender:F
Credentials:PHD, MA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CASHDOLLAR RD
Mailing Address - Street 2:
Mailing Address - City:MARS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-3502
Mailing Address - Country:US
Mailing Address - Phone:724-816-7771
Mailing Address - Fax:844-662-5069
Practice Address - Street 1:TELEHEALTH
Practice Address - Street 2:
Practice Address - City:MARS
Practice Address - State:PA
Practice Address - Zip Code:16046-3502
Practice Address - Country:US
Practice Address - Phone:724-816-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005515101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1538533948OtherNPPES
PA1588983894OtherNPPES
PA474028867OtherCOMMONWEALTH OF PENNSYLVANIA