MEDICARE: MS. REBEKAH LEE FATZINGER LLP, LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301006216	MI
2	1041C0700X	Clinical Social Worker	6801063574	MI

General Provider Information

NPI Number	:	1235300294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REBEKAH LEE FATZINGER LLP, LMSW

Provider Business Mailing Address
First Line	:	28143 SPRINGBROOK DR
Second Line	:
City	:	LAWTON
State	:	MI
Zip	:	49065-9608
Country	:	US
Telephone Number	:	269-624-6153
Fax Number	:

Provider Business Practice Location Address
First Line	:	803 W ARLINGTON ST
Second Line	:
City	:	BANGOR
State	:	MI
Zip	:	49013-1108
Country	:	US
Telephone Number	:	269-427-6810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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