Provider Demographics
NPI:1932860319
Name:TAVARES, FIDEL
Entity type:Individual
Prefix:
First Name:FIDEL
Middle Name:
Last Name:TAVARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAKESHORE CTR UNIT 1238
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-1083
Mailing Address - Country:US
Mailing Address - Phone:617-708-4158
Mailing Address - Fax:
Practice Address - Street 1:231 MAIN ST FL 3
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4342
Practice Address - Country:US
Practice Address - Phone:508-586-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health