Healthcare Provider Details

I. General information

NPI: 1568763977
Provider Name (Legal Business Name): REBEKAH LEE FULLER FRICKE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N CHESTNUT ST STE 244
CHAMPAIGN IL
61820-4856
US

IV. Provider business mailing address

PO BOX 2257
CHESTERTON IN
46304-0357
US

V. Phone/Fax

Practice location:
  • Phone: 217-621-6180
  • Fax:
Mailing address:
  • Phone: 219-926-8320
  • Fax: 219-926-3524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: