Provider Demographics
NPI:1417393463
Name:FACUNDO, REBECCA ANN
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:FACUNDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 EAST HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT EISENHOWER
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:989-778-0460
Mailing Address - Fax:
Practice Address - Street 1:300 EAST HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:FORT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:899-778-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI68010954851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health