Provider Demographics
NPI:1255728002
Name:FABRIC, MOLLIE (MED, BCBA)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:FABRIC
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 146TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-4900
Mailing Address - Country:US
Mailing Address - Phone:206-335-3342
Mailing Address - Fax:
Practice Address - Street 1:510 146TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-4900
Practice Address - Country:US
Practice Address - Phone:206-335-3342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1-14-16912103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1-14-16912OtherBCBA LICENSE
WA47-3763674OtherEIN/TAX ID