Provider Demographics
NPI:1043888506
Name:CARSON, REBECCA J (LBSW)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:J
Last Name:CARSON
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E. 30TH ST. SUITE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402
Mailing Address - Country:US
Mailing Address - Phone:505-599-8612
Mailing Address - Fax:855-290-2205
Practice Address - Street 1:1500 E. 25TH ST.
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-599-8612
Practice Address - Fax:855-290-2205
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-12221041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool