Healthcare Provider Details

I. General information

NPI: 1417393463
Provider Name (Legal Business Name): MRS. REBECCA ANN FACUNDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 03/08/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EAST HOSPITAL ROAD
FORT EISENHOWER GA
30905
US

IV. Provider business mailing address

300 EAST HOSPITAL ROAD
FORT EISENHOWER GA
30905
US

V. Phone/Fax

Practice location:
  • Phone: 899-778-0460
  • Fax:
Mailing address:
  • Phone: 989-778-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095485
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: