Provider Demographics
NPI:1154847606
Name:FABANICH, CORRENE (MS)
Entity Type:Individual
Prefix:MRS
First Name:CORRENE
Middle Name:
Last Name:FABANICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PROFESSIONAL PLZ STE 110
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2049
Mailing Address - Country:US
Mailing Address - Phone:208-359-9570
Mailing Address - Fax:208-359-9580
Practice Address - Street 1:36 PROFESSIONAL PLZ STE 110
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2049
Practice Address - Country:US
Practice Address - Phone:208-359-9570
Practice Address - Fax:208-359-9580
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-3260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist