Provider Demographics
NPI:1780402115
Name:FAIRBANKS, TARA KIM (CAP - 207)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:KIM
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:CAP - 207
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2838
Mailing Address - Country:US
Mailing Address - Phone:307-267-7253
Mailing Address - Fax:
Practice Address - Street 1:1430 WILKINS CIR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1336
Practice Address - Country:US
Practice Address - Phone:307-237-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WY207101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)