Provider Demographics
NPI:1679104491
Name:FRY, REBECCA NICOLE (LLPC, CRC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:NICOLE
Last Name:FRY
Suffix:
Gender:F
Credentials:LLPC, CRC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:NICOLE
Other - Last Name:VRLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRC
Mailing Address - Street 1:7932 GOSHEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-5002
Mailing Address - Country:US
Mailing Address - Phone:214-536-4590
Mailing Address - Fax:
Practice Address - Street 1:7932 GOSHEN DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-5002
Practice Address - Country:US
Practice Address - Phone:214-536-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00116653225C00000X
MI6401018109101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor