Healthcare Provider Details

I. General information

NPI: 1275444267
Provider Name (Legal Business Name): EDWARD LEVAR FAIRLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 PROGRESSIVE DR STE 104
CHESAPEAKE VA
23320-2847
US

IV. Provider business mailing address

1724 LOCKARD AVE
CHESAPEAKE VA
23320-2218
US

V. Phone/Fax

Practice location:
  • Phone: 757-286-2786
  • Fax:
Mailing address:
  • Phone: 757-472-4360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: