Provider Demographics
NPI:1972659878
Name:FAIRBANKS, PATRICIA R (OTRL)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:R
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:R
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTRL
Mailing Address - Street 1:423 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4200
Mailing Address - Country:US
Mailing Address - Phone:631-207-3105
Mailing Address - Fax:
Practice Address - Street 1:423 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4200
Practice Address - Country:US
Practice Address - Phone:631-207-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003149-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist