Provider Demographics
NPI:1932245891
Name:WENTWORTH, REBECCA L (MA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:WENTWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:5455 ALMIRA DR SE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8330
Mailing Address - Country:US
Mailing Address - Phone:360-373-5031
Mailing Address - Fax:
Practice Address - Street 1:900 SHERIDAN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2701
Practice Address - Country:US
Practice Address - Phone:360-415-3866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00009538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91102010626OtherKITSAP PHYSICIANS SERVICE