Basic Information
| Provider Information | |||||||||
| NPI: | 1215442942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRBANKS | ||||||||
| FirstName: | COURTNI | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA-R | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAIRBANKS | ||||||||
| OtherFirstName: | COURTNI | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA-R | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1014 WALLA WALLA AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988011523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096630034 | ||||||||
| FaxNumber: | 5096633726 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 WALLA WALLA AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988011523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096630034 | ||||||||
| FaxNumber: | 5096633726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CG60803223 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.