Healthcare Provider Details

I. General information

NPI: 1982981486
Provider Name (Legal Business Name): CHRISTIANE FONNESBECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 11/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DIANA ST
LUDINGTON MI
49431-1987
US

IV. Provider business mailing address

920 DIANA ST
LUDINGTON MI
49431-1987
US

V. Phone/Fax

Practice location:
  • Phone: 231-845-6294
  • Fax: 231-845-7095
Mailing address:
  • Phone: 231-845-6294
  • Fax: 231-845-7095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: