Provider Demographics
NPI:1699079780
Name:REDD, REBECCA (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:REDD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1917
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-726-3115
Practice Address - Street 1:380 SUWANNEE TRAIL ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7956
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-842-5268
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid