Provider Demographics
NPI:1972645471
Name:FAIRBANK, CARLENE MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARLENE
Middle Name:MARIE
Last Name:FAIRBANK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E MOUNTAIN VISTA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-1918
Mailing Address - Country:US
Mailing Address - Phone:480-460-3906
Mailing Address - Fax:480-460-3290
Practice Address - Street 1:8330 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5904
Practice Address - Country:US
Practice Address - Phone:480-484-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP0398OtherAZ DEPT. HEALTH SERVICE
AZ626814Medicare UPIN