Provider Demographics
NPI:1104324821
Name:FAIR, AMI DANIELLE
Entity type:Individual
Prefix:
First Name:AMI
Middle Name:DANIELLE
Last Name:FAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 ROCKNE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3436
Mailing Address - Country:US
Mailing Address - Phone:248-703-6016
Mailing Address - Fax:
Practice Address - Street 1:3220 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3028
Practice Address - Country:US
Practice Address - Phone:574-222-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221700000X
IN39005230A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist