Basic Information
| Provider Information | |||||||||
| NPI: | 1174014187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | RACHELE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LYNN | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | RACHELE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16941 N EAGLE RIVER LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077265330 | ||||||||
| FaxNumber: | 9077265366 | ||||||||
| Practice Location | |||||||||
| Address1: | 16941 N EAGLE RIVER LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077265330 | ||||||||
| FaxNumber: | 9077265366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2018 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | AK | N | 103K00000X | 167814 | AK | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.