Basic Information
| Provider Information | |||||||||
| NPI: | 1972987998 | ||||||||
| 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 | ||||||||
| TelephoneNumber: | 9075611000 | ||||||||
| FaxNumber: | 9077708917 | ||||||||
| Practice Location | |||||||||
| Address1: | 3830 S CUSHMAN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073711300 | ||||||||
| FaxNumber: | 9077708917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2015 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | MORROW | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9077622820 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANCHORAGE COMMUNITY MENTAL HEALTH SERVICES, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TR0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | 103TP0016X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
ID Information
| ID | Type | State | Issuer | Description | K165350 | 01 | AK | MEDICARE | OTHER |