Healthcare Provider Details

I. General information

NPI: 1750626164
Provider Name (Legal Business Name): CHRISTINA LYNNE DALKE FAIRBANKS PH.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA L KHAN PH.D., M.S.

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612
US

IV. Provider business mailing address

13000 BRUCE B DOWNS BLVD (116A)
TAMPA FL
33612-4745
US

V. Phone/Fax

Practice location:
  • Phone: 813-631-2525
  • Fax: 813-631-7128
Mailing address:
  • Phone: 813-631-2525
  • Fax: 813-631-7128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberT-LMLP 2424
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2013040131
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: