Basic Information
| Provider Information | |||||||||
| NPI: | 1649371634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FABIANO | ||||||||
| FirstName: | SELENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 510 16TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946121520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103575515 | ||||||||
| FaxNumber: | 5103185396 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 16TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946121520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103575515 | ||||||||
| FaxNumber: | 5103185396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY 14541 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ22806Z | 01 | CA | MEDICARE - GROUP PIN | OTHER |