Provider Demographics
NPI:1265496400
Name:FAIR, MARY JEAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JEAN
Last Name:FAIR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:JEAN
Other - Last Name:BROMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:555 E MAIN STREET
Mailing Address - Street 2:SUITE 104A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4850
Mailing Address - Country:US
Mailing Address - Phone:423-245-1355
Mailing Address - Fax:
Practice Address - Street 1:555 E MAIN STREET
Practice Address - Street 2:SUITE 104A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4850
Practice Address - Country:US
Practice Address - Phone:423-245-1355
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW0000000440104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7248099OtherAETNA
TN424652OtherVALUE OPTION
TN141916XXOtherPREFERRED CARE
TN3032073OtherBLUE CROSS BLUE SHIELD
TN11510986OtherCAQU
TN3691161Medicaid
NYNH031OtherEMPIRE BCBS
TN141916XXOtherPREFERRED CARE