Provider Demographics
NPI:1033728043
Name:FAIRBANKS, KRISTINA NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICOLE
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8694 FOREST GLEN CT
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8424
Mailing Address - Country:US
Mailing Address - Phone:630-217-3921
Mailing Address - Fax:
Practice Address - Street 1:1308 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2719
Practice Address - Country:US
Practice Address - Phone:219-663-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-26
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health