Provider Demographics
NPI:1750626164
Name:FAIRBANKS, CHRISTINA LYNNE DALKE (PHD, MS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:LYNNE DALKE
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:PHD, MS
Other - Prefix:DR
Other - First Name:CHRISTINA
Other - Middle Name:L
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, MS
Mailing Address - Street 1:13000 BRUCE B DOWNS BLVD (116A)
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4745
Mailing Address - Country:US
Mailing Address - Phone:813-631-2525
Mailing Address - Fax:813-631-7128
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-631-2525
Practice Address - Fax:813-631-7128
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMLP 2424103TC1900X
MO2013040131103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling