Provider Demographics
NPI:1891521571
Name:FAIRBANKS, BROOKE (LCSW)
Entity type:Individual
Prefix:
First Name:BROOKE
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 1:46 HIGH BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BANTAM
Mailing Address - State:CT
Mailing Address - Zip Code:06750-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257 MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5206
Practice Address - Country:US
Practice Address - Phone:203-558-3975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0141041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty