Healthcare Provider Details

I. General information

NPI: 1114901964
Provider Name (Legal Business Name): WILLIAM D FAIRBANKS PH.D., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 SEYMOUR AVE
CHEYENNE WY
82001-3159
US

IV. Provider business mailing address

2526 SEYMOUR AVE
CHEYENNE WY
82001-3159
US

V. Phone/Fax

Practice location:
  • Phone: 307-634-9653
  • Fax: 307-638-8256
Mailing address:
  • Phone: 307-634-9653
  • Fax: 307-638-8256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number261
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: