Provider Demographics
NPI:1720133648
Name:FABRIC, CAROL ELIZABETH (MFT)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ELIZABETH
Last Name:FABRIC
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MRS
Other - First Name:CAROL
Other - Middle Name:ELIZABETH
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 ENCINA PLACE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960
Mailing Address - Country:US
Mailing Address - Phone:415-721-7864
Mailing Address - Fax:
Practice Address - Street 1:21 ENCINA PLACE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960
Practice Address - Country:US
Practice Address - Phone:415-721-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM13884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist