Provider Demographics
NPI:1780328344
Name:FAIRWAY BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:FAIRWAY BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:937-838-9550
Mailing Address - Street 1:140 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-8008
Mailing Address - Country:US
Mailing Address - Phone:937-992-1057
Mailing Address - Fax:
Practice Address - Street 1:140 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-8008
Practice Address - Country:US
Practice Address - Phone:937-992-1057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty