Provider Demographics
NPI:1083088165
Name:DR FAIRALL AND ASSOCIATES BEHAVIORAL HEALTH AND FAMILY MEDIATION SERVI
Entity type:Organization
Organization Name:DR FAIRALL AND ASSOCIATES BEHAVIORAL HEALTH AND FAMILY MEDIATION SERVI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRALL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:904-463-2284
Mailing Address - Street 1:117 OLD MILL CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4133
Mailing Address - Country:US
Mailing Address - Phone:904-463-2284
Mailing Address - Fax:
Practice Address - Street 1:4400 MARSH LANDING BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-7215
Practice Address - Country:US
Practice Address - Phone:904-463-2284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7675103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264222586OtherOTHER EIN