Healthcare Provider Details

I. General information

NPI: 1023946779
Provider Name (Legal Business Name): OCTAVIA LAINE FABRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E AUGUSTA ST
MC CORMICK SC
29835-8703
US

IV. Provider business mailing address

227 SANDUSKY LN
SIMPSONVILLE SC
29680-7719
US

V. Phone/Fax

Practice location:
  • Phone: 864-550-3900
  • Fax:
Mailing address:
  • Phone: 631-295-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: