Healthcare Provider Details

I. General information

NPI: 1033595665
Provider Name (Legal Business Name): FAIRSKY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23231 WOODWARD AVE
FERNDALE MI
48220-1361
US

IV. Provider business mailing address

23231 WOODWARD AVE
FERNDALE MI
48220-1361
US

V. Phone/Fax

Practice location:
  • Phone: 248-581-8777
  • Fax: 888-975-9374
Mailing address:
  • Phone: 248-581-8777
  • Fax: 888-975-9374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID ST. JOHN
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 248-581-8777