Provider Demographics
NPI:1255739439
Name:WILLSE, REBECCA S (LAC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:WILLSE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1430 HAINES AVE
Mailing Address - Street 2:STE. 108 #177
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-0689
Mailing Address - Country:US
Mailing Address - Phone:605-890-2974
Mailing Address - Fax:
Practice Address - Street 1:550 N 5TH ST
Practice Address - Street 2:STE. 106
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1375
Practice Address - Country:US
Practice Address - Phone:605-718-3620
Practice Address - Fax:605-718-3616
Is Sole Proprietor?:No
Enumeration Date:2014-12-20
Last Update Date:2014-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD09041390101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)