Provider Demographics
NPI:1306015326
Name:FAIRBANK, JOHN ALBERT (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALBERT
Last Name:FAIRBANK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 W MAIN ST
Mailing Address - Street 2:SUITE 24-E
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-2054
Mailing Address - Country:US
Mailing Address - Phone:919-682-1552
Mailing Address - Fax:
Practice Address - Street 1:905 W MAIN ST
Practice Address - Street 2:SUITE 24-E
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2054
Practice Address - Country:US
Practice Address - Phone:919-682-1552
Practice Address - Fax:919-667-9578
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-23
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1398103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical