Healthcare Provider Details

I. General information

NPI: 1063512671
Provider Name (Legal Business Name): REBECCA BENNETT KATOVSICH PHD, LLP, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 MAIN ST
SAINT JOSEPH MI
49085-1426
US

IV. Provider business mailing address

903 MAIN ST
SAINT JOSEPH MI
49085-1426
US

V. Phone/Fax

Practice location:
  • Phone: 269-985-2000
  • Fax: 269-985-2002
Mailing address:
  • Phone: 269-985-2000
  • Fax: 269-985-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801080778
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013818
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080778
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013818
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: