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General NPI Number Information
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NPI Number | 1003630872
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Entity Type | Organization
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Legal Business Name | FAIRBANKS SOMATIC THERAPY AND WELLNESS LLC
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Dates
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Enumeration Date | 11/08/2024
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Last Update Date | 11/08/2024
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Provider Practice Location Address
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Address Line | 250 CUSHMAN ST STE 4E
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City | FAIRBANKS
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State | AK
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Zip | 99701-4665
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Country | US
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Telephone | 907-371-5359
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Fax |
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Provider Business Mailing Address
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Address Line | 1210 YUNANA CT
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City | FAIRBANKS
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State | AK
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Zip | 99701-1426
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Country | US
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Telephone | 907-687-4194
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Fax |
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Authorized Official
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Title or Position | MANAGER AND MEMBER
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Name | BRIGHTON BROOKS
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Credential | LPC
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Telephone | 907-687-4194
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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