Healthcare Provider Details

I. General information

NPI: 1114948460
Provider Name (Legal Business Name): BRIAN FOBIAN CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N84W15787 MENOMONEE AVE SUITE 6
MENOMONEE FALLS WI
53051-3081
US

IV. Provider business mailing address

285 N JANACEK RD
BROOKFIELD WI
53045-6102
US

V. Phone/Fax

Practice location:
  • Phone: 262-255-5571
  • Fax: 262-255-5581
Mailing address:
  • Phone: 262-641-9050
  • Fax: 262-641-9126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10747
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: