Provider Demographics
NPI:1659749604
Name:LAUTERBACH, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LAUTERBACH
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 1:914 BENNETT CT
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184-9689
Mailing Address - Country:US
Mailing Address - Phone:262-275-8376
Mailing Address - Fax:
Practice Address - Street 1:1575 W LAKE SHORE DR
Practice Address - Street 2:BENNETT
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-6917
Practice Address - Country:US
Practice Address - Phone:262-214-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004444235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist