Healthcare Provider Details

I. General information

NPI: 1023377694
Provider Name (Legal Business Name): FIDELIS N SAB CAC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032-1573
US

IV. Provider business mailing address

7903 ORION CIR APT C215
LAUREL MD
20724-3101
US

V. Phone/Fax

Practice location:
  • Phone: 202-800-4433
  • Fax:
Mailing address:
  • Phone: 240-350-9677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCACII200001262
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: