Healthcare Provider Details

I. General information

NPI: 1023445871
Provider Name (Legal Business Name): FAIRBANKS COMMUNITY MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 S CUSHMAN ST
FAIRBANKS AK
99701-7530
US

IV. Provider business mailing address

1423 PEGER RD
FAIRBANKS AK
99709-5169
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-1575
  • Fax: 907-455-5287
Mailing address:
  • Phone: 907-371-1300
  • Fax: 907-371-1386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DARCIE M SHAFFER
Title or Position: MEDICAL BILLING MANAGER
Credential: BAS, CPC
Phone: 907-563-1000