Healthcare Provider Details

I. General information

NPI: 1033870829
Provider Name (Legal Business Name): KALEY FAIRBAIRN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 RUPERT ST NE
GRAND RAPIDS MI
49525-2861
US

IV. Provider business mailing address

1960 RUPERT ST NE
GRAND RAPIDS MI
49525-2861
US

V. Phone/Fax

Practice location:
  • Phone: 616-540-6010
  • Fax:
Mailing address:
  • Phone: 616-540-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KALEY FAIRBAIRN
Title or Position: OWNER
Credential: LMSW
Phone: 616-540-6010