Organization
BEHAVIORAL HEALTH SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THOMAS FAIRBANK PH.D. (PRES/OWNER)
(801) 773-7177
Entity
Organization
Contact information
Practice address
3225 W GORDON AVE, LAYTON, UT 84041-6508
(801) 773-7177
(801) 498-7562
Mailing address
1767 N 2525 E, LAYTON, UT 84040
(801) 773-7177
(801) 498-7562
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
—
—
1041C0700X
Clinical Social Worker
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000055010
MEDICARE ID-PIN
UT
Enumeration date
12/05/2005
Last updated
07/14/2011
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