Provider Demographics
NPI:1578242939
Name:FAIRBANKS, CHAD (PTA)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 WHISPERING WAY
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-6909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5069 OTTERBEIN WAY
Practice Address - Street 2:
Practice Address - City:MONCLOVA
Practice Address - State:OH
Practice Address - Zip Code:43542-8500
Practice Address - Country:US
Practice Address - Phone:419-878-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09553225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant