Provider Demographics
NPI:1114018231
Name:FAIRCHILD, STEPHANIE TUESDAY
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:TUESDAY
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 GLENDALE LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2611
Mailing Address - Country:US
Mailing Address - Phone:916-641-9595
Mailing Address - Fax:916-641-9599
Practice Address - Street 1:2330 GLENDALE LN
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2611
Practice Address - Country:US
Practice Address - Phone:916-641-9595
Practice Address - Fax:916-641-9599
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF43278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist