Provider Demographics
NPI:1316936578
Name:FAIR, ELISE S (MA, LPC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:S
Last Name:FAIR
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-8111
Mailing Address - Country:US
Mailing Address - Phone:970-352-6120
Mailing Address - Fax:
Practice Address - Street 1:2624 18TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4024
Practice Address - Country:US
Practice Address - Phone:970-674-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional