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General NPI Number Information
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NPI Number | 1730507989
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Entity Type | Individual
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Provider Name | MS. DEMETRIA RENEE FAIRLEY
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Gender | Female
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Dates
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Enumeration Date | 04/04/2014
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Last Update Date | 03/15/2021
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Provider Practice Location Address
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Address Line | 8310 ROSE PETALS LN
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City | ROSHARON
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State | TX
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Zip | 77583-1907
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Country | US
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Telephone | 346-305-1688
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Fax |
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Provider Business Mailing Address
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Address Line | 8310 ROSE PETALS LN
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City | ROSHARON
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State | TX
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Zip | 77583-1907
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Country | US
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Telephone | 346-305-1688
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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Taxonomy #2
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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Taxonomy #3
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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Taxonomy #4
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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