Provider Demographics
NPI:1881945392
Name:FULLER, REBECCA ANN (MS CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 COUNTY HIGHWAY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2656
Mailing Address - Country:US
Mailing Address - Phone:715-723-9341
Mailing Address - Fax:
Practice Address - Street 1:2815 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2656
Practice Address - Country:US
Practice Address - Phone:715-723-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist