Provider Demographics
NPI:1699249052
Name:FABIAN, MARLENE
Entity type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:
Last Name:FABIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:FABIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1014 GERARD AVE APT 5G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-9234
Mailing Address - Country:US
Mailing Address - Phone:646-879-6673
Mailing Address - Fax:
Practice Address - Street 1:466 MAIN ST STE LL20
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-6431
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician