Healthcare Provider Details

I. General information

NPI: 1972987998
Provider Name (Legal Business Name): FAIRBANKS COMMUNITY MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 S CUSHMAN ST
FAIRBANKS AK
99701-7530
US

IV. Provider business mailing address

4020 FOLKER ST
ANCHORAGE AK
99508-5321
US

V. Phone/Fax

Practice location:
  • Phone: 907-371-1300
  • Fax: 907-770-8917
Mailing address:
  • Phone: 907-561-1000
  • Fax: 907-770-8917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: AMY MORROW
Title or Position: BILLING MANAGER
Credential:
Phone: 907-762-2820