Provider Demographics
NPI:1790367175
Name:FAIR, BRIANA T
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:T
Last Name:FAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25800 INDUSTRIAL BLVD APT M414
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-2997
Mailing Address - Country:US
Mailing Address - Phone:619-756-3106
Mailing Address - Fax:
Practice Address - Street 1:200 FRANKLIN PKWY
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1921
Practice Address - Country:US
Practice Address - Phone:650-522-7729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA103188104100000X
CA1231461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker