Basic Information
| Provider Information | |||||||||
| NPI: | 1265581425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRBANKS COMMUNITY MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3830 SOUTH CUSHMAN STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521575 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3830 SOUTH CUSHMAN STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 04/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | ATCHISON | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9074521575 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 68067 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MH0157 | 05 | AK | MEDICAID |