Provider Demographics
NPI:1255526182
Name:FAIR, GARDNER HUTCHESON (MFT)
Entity type:Individual
Prefix:
First Name:GARDNER
Middle Name:HUTCHESON
Last Name:FAIR
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 29TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3549
Mailing Address - Country:US
Mailing Address - Phone:510-927-7251
Mailing Address - Fax:510-832-2562
Practice Address - Street 1:400 29TH ST STE 401
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3549
Practice Address - Country:US
Practice Address - Phone:510-927-7251
Practice Address - Fax:510-832-2562
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44741106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000008166-01674804Medicaid