Provider Demographics
NPI:1407073869
Name:FAIR, MARVELL SR
Entity Type:Individual
Prefix:
First Name:MARVELL
Middle Name:
Last Name:FAIR
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-2023
Mailing Address - Country:US
Mailing Address - Phone:901-577-0200
Mailing Address - Fax:901-577-0229
Practice Address - Street 1:427 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-2023
Practice Address - Country:US
Practice Address - Phone:901-577-0200
Practice Address - Fax:901-577-0229
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health