Provider Demographics
NPI:1568763977
Name:FULLER FRICKE, REBEKAH LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:REBEKAH
Middle Name:LEE
Last Name:FULLER FRICKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:100 N CHESTNUT ST STE 244
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4856
Practice Address - Country:US
Practice Address - Phone:217-621-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008014103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical