Healthcare Provider Details

I. General information

NPI: 1720242399
Provider Name (Legal Business Name): ALICIA V FAHR PH.D. LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

1361 BRANCHWOOD CIR APT 201
NAPERVILLE IL
60563-4107
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-5000
  • Fax:
Mailing address:
  • Phone: 612-747-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401224437
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.016233
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401224437
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: