MEDICARE: NATHALIE DE FABRIQUE, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY7421	FL

General Provider Information

NPI Number	:	1124379417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATHALIE DE FABRIQUE, PA

Provider Business Mailing Address
First Line	:	2410 BELLAROSA CIR
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-1469
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1019 N STATE ROAD 7
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-5100
Country	:	US
Telephone Number	:	954-325-3454
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. NATHALIE DE FABRIQUE
Credential	:	PSY.D.
Telephone Number	:	954-325-3454

Provider Enumeration Date	:	09/26/2012
Last Update Date	:	09/26/2012

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