Provider Demographics
NPI:1992883417
Name:FAIRBANKS, JOEL K (PHD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:K
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:PHD
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 18487
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32523-8487
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:8474 UNIVERSITY PARKWAY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514
Practice Address - Country:US
Practice Address - Phone:850-384-4125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004557103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104720OtherVALUE OPTIONS
FL73807OtherBLUE CROSS BLUE SHIELD
FL104720OtherVALUE OPTIONS