Healthcare Provider Details

I. General information

NPI: 1053244418
Provider Name (Legal Business Name): AMY FAIRCHILD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 PARK AVE
GRAND HAVEN MI
49417-2112
US

IV. Provider business mailing address

1031 N MEADOWBROOK
WHITE CLOUD MI
49349-8638
US

V. Phone/Fax

Practice location:
  • Phone: 616-209-8817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451024531
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: