Provider Demographics
NPI:1588089049
Name:FAIRBANKS, REBECCA CHRISTENSEN (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:CHRISTENSEN
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1760 W 4805 S
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-1177
Mailing Address - Country:US
Mailing Address - Phone:801-955-9110
Mailing Address - Fax:801-955-9411
Practice Address - Street 1:2020 S LAKE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3119
Practice Address - Country:US
Practice Address - Phone:801-487-7778
Practice Address - Fax:435-652-6354
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8890207-35011041C0700X
MA1171441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical