Provider Demographics
NPI:1679963896
Name:FAIRBAIRN, GABRIELLE RENEE (BCBA)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:RENEE
Last Name:FAIRBAIRN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19019 VENTURA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3253
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:818-758-8015
Practice Address - Street 1:212 S MARION ST
Practice Address - Street 2:SUITE 11
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3159
Practice Address - Country:US
Practice Address - Phone:708-358-3000
Practice Address - Fax:708-524-0299
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-14-17317103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst