Healthcare Provider Details

I. General information

NPI: 1629988225
Provider Name (Legal Business Name): FABIOLA THEODORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CLEMENS AVE
BROCKTON MA
02302-2155
US

IV. Provider business mailing address

4 POST OFFICE SQ
TAUNTON MA
02780-3207
US

V. Phone/Fax

Practice location:
  • Phone: 774-360-4551
  • Fax:
Mailing address:
  • Phone: 781-300-8917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: