Provider Demographics
NPI:1285933358
Name:FAIRBANKS, KATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 N LAKEWOOD DR STE 226
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2473
Mailing Address - Country:US
Mailing Address - Phone:208-819-8321
Mailing Address - Fax:208-620-2178
Practice Address - Street 1:2101 N LAKEWOOD DR STE 226
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2473
Practice Address - Country:US
Practice Address - Phone:208-819-8321
Practice Address - Fax:208-620-2178
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-329491041C0700X
IDLMSW-248401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical