1265496400 NPI number — MS. MARY JEAN FAIR LCSW

Table of content: MS. MARY JEAN FAIR LCSW (NPI 1265496400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265496400 NPI number — MS. MARY JEAN FAIR LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIR
Provider First Name:
MARY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROMLEY
Provider Other First Name:
MARY
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265496400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 E MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 104A
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-4850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-245-1355
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 E MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 104A
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-245-1355
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LSW0000000440 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7248099 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 424652 . This is a "VALUE OPTION" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 141916XX . This is a "PREFERRED CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3032073 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 11510986 . This is a "CAQU" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3691161 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: NH031 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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