Provider Demographics
NPI:1659777225
Name:FAIR, DORIS STACY (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:DORIS
Middle Name:STACY
Last Name:FAIR
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 LINTON RUN ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904
Mailing Address - Country:US
Mailing Address - Phone:443-907-8041
Mailing Address - Fax:410-378-4162
Practice Address - Street 1:501 SOUTH UNION AVE.
Practice Address - Street 2:HARFORD MEMORIAL HOSPITAL
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078
Practice Address - Country:US
Practice Address - Phone:443-843-8047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8876101YM0800X, 101YP2500X
MDS0000060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant