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General NPI Number Information
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NPI Number | 1023377694
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Entity Type | Individual
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Provider Name | FIDELIS N SAB CAC II
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Gender | Male
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Dates
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Enumeration Date | 05/16/2012
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 3109 MARTIN LUTHER KING JR AVE SE
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City | WASHINGTON
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State | DC
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Zip | 20032-1573
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Country | US
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Telephone | 202-800-4433
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Fax |
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Provider Business Mailing Address
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Address Line | 7903 ORION CIR APT C215
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City | LAUREL
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State | MD
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Zip | 20724-3101
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Country | US
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Telephone | 240-350-9677
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | CACII200001262
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License Number State |
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