Provider Demographics
NPI:1508252867
Name:LEWIS A. FABRICK, PHD, PA
Entity Type:Organization
Organization Name:LEWIS A. FABRICK, PHD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FABRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:352-338-0397
Mailing Address - Street 1:2833 NW 41ST ST STE 140
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6987
Mailing Address - Country:US
Mailing Address - Phone:352-338-0397
Mailing Address - Fax:352-372-6787
Practice Address - Street 1:2833 NW 41ST ST STE 140
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6987
Practice Address - Country:US
Practice Address - Phone:352-338-0397
Practice Address - Fax:352-372-6787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW5601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ0973AOtherMEDICARE PTAN
FLZ0937OtherBCBS