1679963896 NPI number — GABRIELLE RENEE FAIRBAIRN BCBA

Table of content: GABRIELLE RENEE FAIRBAIRN BCBA (NPI 1679963896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679963896 NPI number — GABRIELLE RENEE FAIRBAIRN BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRBAIRN
Provider First Name:
GABRIELLE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679963896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19019 VENTURA BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-3253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-345-2345
Provider Business Mailing Address Fax Number:
818-758-8015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 S MARION ST
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60302-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-358-3000
Provider Business Practice Location Address Fax Number:
708-524-0299
Provider Enumeration Date:
01/26/2015

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: 103K00000X , with the licence number:  1-14-17317 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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