Basic Information
| Provider Information | |||||||||
| NPI: | 1699974782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGELBERG | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | BERENT | ||||||||
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| Credential: | LMSW | ||||||||
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| OtherLastName: | BERENT | ||||||||
| OtherFirstName: | RACHEL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2101 COMMONWEALTH | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005255188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801084583 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801084583 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.