Provider Demographics
NPI:1104930346
Name:FABIAN, MARK ANTHONY (LMHC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:FABIAN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:MILLIS
Mailing Address - State:MA
Mailing Address - Zip Code:02054-1026
Mailing Address - Country:US
Mailing Address - Phone:508-376-4405
Mailing Address - Fax:
Practice Address - Street 1:20 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1942
Practice Address - Country:US
Practice Address - Phone:508-904-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4863101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health