Provider Demographics
NPI:1588635197
Name:FAIRBANK, JOAN (PT)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:FAIRBANK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10085 RED RUN BLVD STE 307
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4832
Mailing Address - Country:US
Mailing Address - Phone:410-363-7123
Mailing Address - Fax:410-363-0054
Practice Address - Street 1:10085 RED RUN BLVD STE 307
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4832
Practice Address - Country:US
Practice Address - Phone:410-363-7123
Practice Address - Fax:410-363-0054
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
21961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5577Medicare ID - Type Unspecified
NYQ34738Medicare UPIN