Provider Demographics
NPI:1508226424
Name:FABERA, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FABERA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13156
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3156
Mailing Address - Country:US
Mailing Address - Phone:920-403-7600
Mailing Address - Fax:920-403-7360
Practice Address - Street 1:1511 W MAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9556
Practice Address - Country:US
Practice Address - Phone:920-403-7600
Practice Address - Fax:920-403-7360
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8448-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical