Provider Demographics
NPI:1972988020
Name:FIELDS, MARY FAYE (PSYD, BCBA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:FAYE
Last Name:FIELDS
Suffix:
Gender:F
Credentials:PSYD, BCBA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:FAYE
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LP,PSYD, BCBA, LABA
Mailing Address - Street 1:400 TRANQUILITY TRCE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4015
Mailing Address - Country:US
Mailing Address - Phone:260-705-5507
Mailing Address - Fax:
Practice Address - Street 1:400 TRANQUILITY TRCE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4015
Practice Address - Country:US
Practice Address - Phone:260-705-5507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001567103K00000X
VA0810006368103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1472090Medicaid