=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821782400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THREE FATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2023
-----------------------------------------------------
Last Update Date | 06/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 754 PINE ST
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49442-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-724-1444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 754 PINE ST
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49442-1019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-724-1444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW/GROUP OWNER
-----------------------------------------------------
Name | REBECCA NEWMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-724-1444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------