Provider Demographics
NPI:1003630872
Name:FAIRBANKS SOMATIC THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:FAIRBANKS SOMATIC THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER AND MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIGHTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:907-687-4194
Mailing Address - Street 1:1210 YUNANA CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-1426
Mailing Address - Country:US
Mailing Address - Phone:907-687-4194
Mailing Address - Fax:
Practice Address - Street 1:250 CUSHMAN ST STE 4E
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4665
Practice Address - Country:US
Practice Address - Phone:907-371-5359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty