Provider Demographics
NPI:1649021510
Name:REBECCA FONVILLE PSYD LLC
Entity type:Organization
Organization Name:REBECCA FONVILLE PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-809-4077
Mailing Address - Street 1:12801 N CENTRAL EXPY STE 1730
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-1872
Mailing Address - Country:US
Mailing Address - Phone:773-809-4077
Mailing Address - Fax:
Practice Address - Street 1:12801 N CENTRAL EXPY STE 1730
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1872
Practice Address - Country:US
Practice Address - Phone:773-809-4077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty