Coyote Fairbank, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

BBH-LCSW-LIC-23635 Issued in MT

Practice address

2 6TH Ave E
Polson, MT 59860-2726

Phone

(406) 214-3137

NPI assigned

Apr 10, 2017

Last updated

Nov 27, 2023By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Jul 1, 2024 through Jul 1, 2028

Medicare enrollment (NPD)

Enrolled

State licenses

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Fairbank Counseling, PLLC

  • Clinical Social Worker
  • Polson, MT
  • NPI 1396410130
  Authorized official Same address or phone

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1491782400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1701043200000",
    "number": "1447783170",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 181",
            "city": "POLSON",
            "state": "MT",
            "postal_code": "598600181",
            "telephone_number": "406-214-3137"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2 6TH AVE E",
            "city": "POLSON",
            "state": "MT",
            "postal_code": "598602726",
            "telephone_number": "406-214-3137"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7935 Mt Highway 35 Ste 202",
            "address_purpose": "LOCATION",
            "city": "Bigfork",
            "state": "MT",
            "postal_code": "599115711",
            "country_code": "US",
            "telephone_number": "406-214-3137",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1602 2nd St W",
            "address_purpose": "LOCATION",
            "city": "Polson",
            "state": "MT",
            "postal_code": "598604005",
            "country_code": "US",
            "telephone_number": "406-214-3137",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FAIRBANK",
        "first_name": "COYOTE",
        "credential": "LCSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-04-10",
        "last_updated": "2023-11-27",
        "certification_date": "2020-10-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MT",
            "license": "BBH-LCSW-LIC-23635",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "krmcmedicalrecords@krhdirect.org",
            "affiliation": "Y",
            "address_1": "106 Ridgewater Dr Ste A",
            "city": "Polson",
            "state": "MT",
            "country_code": "US",
            "postal_code": "598608977",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Jamie Michael Engeldrum, PA-C
• Donald Paul Ericksen, M.D.
• David Jason Erickson I, L.M.T
• Evergreen at Polson, L.L.C. (Polson Health and Rehabilitation Center)
• Fairbank Counseling, PLLC
• Shaina Lynn Fairbank, LCSW
• Sandra Fisher, PHARM. D.
• Travis Ladel Fisher, RDH
• Michael J Flannery, MD
• Megan Elizabeth Fogle

• Clinical Social Worker in Polson, MT
• Providers in Polson, MT by specialty
• Clinical Social Worker in Montana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.