Healthcare Provider Details

I. General information

NPI: 1013267756
Provider Name (Legal Business Name): INDY MARIE FAIRBANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N RIVER ST STE 200
DERBY KS
67037-1539
US

IV. Provider business mailing address

215 E 9TH AVE
BELLE PLAINE KS
67013-8823
US

V. Phone/Fax

Practice location:
  • Phone: 316-409-0565
  • Fax:
Mailing address:
  • Phone: 316-633-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number647
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4661
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: