Provider Demographics
NPI:1932108990
Name:FABRICK, LEWIS A (PHD, PA)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:A
Last Name:FABRICK
Suffix:
Gender:M
Credentials:PHD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2833 NW 41ST ST
Mailing Address - Street 2:#140
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6986
Mailing Address - Country:US
Mailing Address - Phone:352-338-0397
Mailing Address - Fax:352-372-6787
Practice Address - Street 1:2833 NW 41ST ST
Practice Address - Street 2:#140
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6986
Practice Address - Country:US
Practice Address - Phone:352-338-0397
Practice Address - Fax:352-372-6787
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW5601041C0700X
FLMT160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ0973AMedicare UPIN