1568763977 NPI number — DR. REBEKAH LEE FULLER FRICKE PSYD

Table of content: DR. REBEKAH LEE FULLER FRICKE PSYD (NPI 1568763977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568763977 NPI number — DR. REBEKAH LEE FULLER FRICKE PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER FRICKE
Provider First Name:
REBEKAH
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568763977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2257
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46304-0357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-926-8320
Provider Business Mailing Address Fax Number:
219-926-3524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N CHESTNUT ST STE 244
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-4856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-621-6180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071008014 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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