Provider Demographics
NPI:1568677839
Name:FAIRLIE, RUSSELL A (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:FAIRLIE
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 1:1160 LIMEKILN PIKE
Mailing Address - Street 2:BOX 303
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044-0303
Mailing Address - Country:US
Mailing Address - Phone:215-646-4282
Mailing Address - Fax:
Practice Address - Street 1:1160 LIMEKILN PK.
Practice Address - Street 2:BOX 303
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-0303
Practice Address - Country:US
Practice Address - Phone:215-646-4282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-003279-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist