Provider Demographics
NPI:1215442942
Name:FAIRBANKS, COURTNI DENISE (MA-R)
Entity type:Individual
Prefix:
First Name:COURTNI
Middle Name:DENISE
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:MA-R
Other - Prefix:
Other - First Name:COURTNI
Other - Middle Name:DENISE
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA-R
Mailing Address - Street 1:1014 WALLA WALLA AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1523
Mailing Address - Country:US
Mailing Address - Phone:509-663-0034
Mailing Address - Fax:509-663-3726
Practice Address - Street 1:1014 WALLA WALLA AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1523
Practice Address - Country:US
Practice Address - Phone:509-663-0034
Practice Address - Fax:509-663-3726
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60803223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health