Basic Information
| Provider Information | |||||||||
| NPI: | 1568763977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER FRICKE | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
| FaxNumber: | 2199263524 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N CHESTNUT ST STE 244 | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618204856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071008014 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.