Provider Demographics
NPI:1467981050
Name:FAIRLEY, MARTHA (MA, LPC, LMHCA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:MA, LPC, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 E HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2629
Mailing Address - Country:US
Mailing Address - Phone:509-684-4597
Mailing Address - Fax:
Practice Address - Street 1:982 E COLUMBIA AVE STE 201
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3316
Practice Address - Country:US
Practice Address - Phone:509-685-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6745101YM0800X
WAMC60864281101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC60864281OtherWASHINGTON DEPARTMENT OF HEALTH
IDLPC-6745OtherIDAHO BUREAU OF OCCUPATIONAL LICENSES