Basic Information
| Provider Information | |||||||||
| NPI: | 1396417325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRBANKS COMMUNITY MENTAL HEALTH SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4020 FOLKER ST | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085321 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1521 HILTON AVE | ||||||||
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| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075631000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | EVENSON | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9072615317 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1598661 | 05 | AK | MEDICAID |