Provider Demographics
NPI:1376324871
Name:FAIR, ANTHONY JAMES (QMHP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JAMES
Last Name:FAIR
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10257 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4418
Mailing Address - Country:US
Mailing Address - Phone:217-520-5315
Mailing Address - Fax:
Practice Address - Street 1:104 NORTHTOWN RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1081
Practice Address - Country:US
Practice Address - Phone:681-282-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2437595101YS0200X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool