Provider Demographics
NPI:1730903774
Name:FAIRCHILD, BENJAMIN MICHAEL
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8816 GORE ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80007-7312
Mailing Address - Country:US
Mailing Address - Phone:303-817-4185
Mailing Address - Fax:
Practice Address - Street 1:14950 W 64TH AVE STE C
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-8291
Practice Address - Country:US
Practice Address - Phone:720-673-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT24-377040106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician