MEDICARE: FABRICE ROBERT LUBIN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071.009410	IL

General Provider Information

NPI Number	:	1558805564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FABRICE ROBERT LUBIN PSYD

Provider Business Mailing Address
First Line	:	1564 N DAMEN AVE STE 208
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2102
Country	:	US
Telephone Number	:	954-559-0073
Fax Number	:	773-409-5008

Provider Business Practice Location Address
First Line	:	1564 N DAMEN AVE STE 208
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2102
Country	:	US
Telephone Number	:	773-888-1681
Fax Number	:	773-409-5008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2016
Last Update Date	:	09/29/2020

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