Provider Demographics
NPI:1225670292
Name:FABAL, KALI MYRELL
Entity type:Individual
Prefix:
First Name:KALI
Middle Name:MYRELL
Last Name:FABAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-2424
Mailing Address - Country:US
Mailing Address - Phone:202-315-8161
Mailing Address - Fax:
Practice Address - Street 1:2700 W CYPRESS CREEK RD STE D131
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1753
Practice Address - Country:US
Practice Address - Phone:954-486-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW148031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW14803Medicaid