Provider Demographics
NPI:1295107423
Name:FABRY, MARY ANN THERESA (CADCII)
Entity type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:THERESA
Last Name:FABRY
Suffix:
Gender:F
Credentials:CADCII
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 1962
Mailing Address - Street 2:105 W Q STREET #5 SPRINGFIELD, OR 97477
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1962
Mailing Address - Country:US
Mailing Address - Phone:541-510-2548
Mailing Address - Fax:541-741-0522
Practice Address - Street 1:105 W Q ST STE 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2188
Practice Address - Country:US
Practice Address - Phone:541-510-2548
Practice Address - Fax:541-741-0522
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01-07-79101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)