Provider Demographics
NPI:1487939575
Name:FAIRBAIRN, SUSAN ROSE (COTA)
Entity type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:ROSE
Last Name:FAIRBAIRN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:MARGARETVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12455-0319
Mailing Address - Country:US
Mailing Address - Phone:845-586-2647
Mailing Address - Fax:845-586-2949
Practice Address - Street 1:415 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MARGARETVILLE
Practice Address - State:NY
Practice Address - Zip Code:12455-0319
Practice Address - Country:US
Practice Address - Phone:845-586-2647
Practice Address - Fax:845-586-2949
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006720172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker