Provider Demographics
NPI:1528236098
Name:FABIAN, MICKI J (MED)
Entity type:Individual
Prefix:MS
First Name:MICKI
Middle Name:J
Last Name:FABIAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:MICKI
Other - Middle Name:J
Other - Last Name:KARWACKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1613 K AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2844
Mailing Address - Country:US
Mailing Address - Phone:541-663-8801
Mailing Address - Fax:
Practice Address - Street 1:1613 K AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2844
Practice Address - Country:US
Practice Address - Phone:541-663-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR74983101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor