Provider Demographics
NPI:1962178335
Name:FOULKS, RACHAEL (BCBA)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:FOULKS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19050 LAYDEN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-2025
Mailing Address - Country:US
Mailing Address - Phone:574-360-1565
Mailing Address - Fax:
Practice Address - Street 1:2505 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2635
Practice Address - Country:US
Practice Address - Phone:574-289-4831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-21-51045103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst