Provider Demographics
NPI:1669978656
Name:FAIRBORN MENTAL HEALTH LLC
Entity type:Organization
Organization Name:FAIRBORN MENTAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:937-768-6867
Mailing Address - Street 1:323 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-4934
Mailing Address - Country:US
Mailing Address - Phone:937-318-8103
Mailing Address - Fax:
Practice Address - Street 1:323 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-4934
Practice Address - Country:US
Practice Address - Phone:937-318-8103
Practice Address - Fax:937-867-5268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.18073363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty