Healthcare Provider Details

I. General information

NPI: 1376324871
Provider Name (Legal Business Name): ANTHONY JAMES FAIR MA QMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 NORTHTOWN DR
SPARTA IL
62286-1081
US

IV. Provider business mailing address

10257 STATE ROUTE 3
RED BUD IL
62278-4418
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-6233
  • Fax:
Mailing address:
  • Phone: 217-520-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2437595
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: