Provider Demographics
NPI:1194039909
Name:FAIRBROTHER, DANA (MS)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:FAIRBROTHER
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 1:900 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2005
Mailing Address - Country:US
Mailing Address - Phone:509-758-3341
Mailing Address - Fax:509-769-6057
Practice Address - Street 1:900 7TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2005
Practice Address - Country:US
Practice Address - Phone:509-758-3341
Practice Address - Fax:509-769-6057
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60150896101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60150896OtherWASHINGTON STATE LICENSE