Provider Demographics
NPI:1821623604
Name:FAIRBAIRN, ROSE KATHARINE (SLP)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:KATHARINE
Last Name:FAIRBAIRN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:K
Other - Last Name:WATSEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10841 GARLAND DR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3703
Mailing Address - Country:US
Mailing Address - Phone:818-324-2292
Mailing Address - Fax:
Practice Address - Street 1:3521 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5039
Practice Address - Country:US
Practice Address - Phone:310-856-8528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty