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General NPI Number Information
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NPI Number | 1659749604
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Entity Type | Individual
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Provider Name | REBECCA LAUTERBACH
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Gender | Female
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Dates
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Enumeration Date | 09/08/2015
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Last Update Date | 09/08/2015
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Provider Practice Location Address
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Address Line | 1575 W LAKE SHORE DR BENNETT
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City | WOODSTOCK
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State | IL
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Zip | 60098-6917
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Country | US
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Telephone | 262-214-6425
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Fax |
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Provider Business Mailing Address
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Address Line | 914 BENNETT CT
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City | WALWORTH
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State | WI
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Zip | 53184-9689
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Country | US
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Telephone | 262-275-8376
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 146.004444
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License Number State | IL
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