| NPI | 1316382492 |
|---|---|
| Former Name | ALLYSE ANN FAIRBANKS |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MI 6401014454) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: NM T-0157441) |
| Enumeration Date | 2013-05-02 |
| Last Update Date | 2017-07-12 |