Provider Demographics
NPI:1144787151
Name:FAIRLEY, HEATHER RENEE (RBT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RENEE
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-1008
Mailing Address - Country:US
Mailing Address - Phone:228-493-9583
Mailing Address - Fax:
Practice Address - Street 1:32 MILLBRANCH RD STE 40
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1673
Practice Address - Country:US
Practice Address - Phone:601-255-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18-47592106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician