MEDICARE: DR. LEWIS A FABRICK PHD, 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	1041C0700X	Clinical Social Worker	SW560	FL
2	106H00000X	Marriage & Family Therapist	MT160	FL

General Provider Information

NPI Number	:	1932108990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEWIS A FABRICK PHD, PA

Provider Business Mailing Address
First Line	:	2833 NW 41ST ST
Second Line	:	#140
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-6986
Country	:	US
Telephone Number	:	352-338-0397
Fax Number	:	352-372-6787

Provider Business Practice Location Address
First Line	:	2833 NW 41ST ST
Second Line	:	#140
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-6986
Country	:	US
Telephone Number	:	352-338-0397
Fax Number	:	352-372-6787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	06/02/2015

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