Provider Demographics
NPI:1346592185
Name:FAIRLY, MARIKO OKANO (BCBA)
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:OKANO
Last Name:FAIRLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MARIKO
Other - Middle Name:HOLMES
Other - Last Name:OKANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:6167 BRISTOL PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6610
Mailing Address - Country:US
Mailing Address - Phone:310-410-4450
Mailing Address - Fax:
Practice Address - Street 1:6167 BRISTOL PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-410-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-7078103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst