=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326649062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA FABIANEK OTD, OTR/L, CBIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2020
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 MAIN ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04240-7041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-795-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 LIBBY RD
-----------------------------------------------------
City | MINOT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04258-5448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-888-3659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT4431
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------