Provider Demographics
NPI:1730507989
Name:FAIRLEY, DEMETRIA RENEE
Entity type:Individual
Prefix:MS
First Name:DEMETRIA
Middle Name:RENEE
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8310 ROSE PETALS LN
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1907
Mailing Address - Country:US
Mailing Address - Phone:346-305-1688
Mailing Address - Fax:
Practice Address - Street 1:8310 ROSE PETALS LN
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-1907
Practice Address - Country:US
Practice Address - Phone:346-305-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No385H00000XRespite Care FacilityRespite Care