Basic Information
| Provider Information | |||||||||
| NPI: | 1225346125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRALL | ||||||||
| FirstName: | DEIDRE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E LAHARPE ST | ||||||||
| Address2: | |||||||||
| City: | KIRKSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606651962 | ||||||||
| FaxNumber: | 6606653989 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 NE WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640865594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163478777 | ||||||||
| FaxNumber: | 8164747671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 09/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 002331 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.