Healthcare Provider Details

I. General information

NPI: 1366099756
Provider Name (Legal Business Name): FABIANO LEITE CORDEIRO LICSW, MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HIGHLAND ST APT 110
TAUNTON MA
02780-4739
US

IV. Provider business mailing address

125 HIGHLAND ST APT 110
TAUNTON MA
02780-4739
US

V. Phone/Fax

Practice location:
  • Phone: 508-828-1308
  • Fax:
Mailing address:
  • Phone: 508-837-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1144294
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: