Provider Demographics
NPI:1356958508
Name:FAIRBOURN, SHARON V (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:V
Last Name:FAIRBOURN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6410
Mailing Address - Country:US
Mailing Address - Phone:435-797-9234
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:6410 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6410
Practice Address - Country:US
Practice Address - Phone:435-797-9234
Practice Address - Fax:844-308-5865
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10579748-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235374984OtherCLINIC NPI