Provider Demographics
NPI:1790367175
Name:FAIR, BRIANA T
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:T
Last Name:FAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ELM ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3070
Mailing Address - Country:US
Mailing Address - Phone:650-591-9623
Mailing Address - Fax:
Practice Address - Street 1:610 ELM ST STE 212
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3070
Practice Address - Country:US
Practice Address - Phone:650-591-9623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA103188104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker