Provider Demographics
NPI:1760014112
Name:CARMONA, FABIAN
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:CARMONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 AVENUE Q SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-3700
Mailing Address - Country:US
Mailing Address - Phone:806-472-3400
Mailing Address - Fax:
Practice Address - Street 1:6104 AVENUE Q SOUTH DR
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-3700
Practice Address - Country:US
Practice Address - Phone:806-472-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW136361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical