Healthcare Provider Details

I. General information

NPI: 1235300294
Provider Name (Legal Business Name): REBEKAH LEE FATZINGER LLP, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W ARLINGTON ST
BANGOR MI
49013-1108
US

IV. Provider business mailing address

28143 SPRINGBROOK DR
LAWTON MI
49065-9608
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-6810
  • Fax:
Mailing address:
  • Phone: 269-624-6153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301006216
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801063574
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: