Healthcare Provider Details

I. General information

NPI: 1891938445
Provider Name (Legal Business Name): JAMAL ORBANO FAIRCHILD EL MA, LLPC, CAAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21700 GREENFIELD RD STE 130
OAK PARK MI
48237-2581
US

IV. Provider business mailing address

21700 GREENFIELD RD STE 130
OAK PARK MI
48237-2581
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-4310
  • Fax: 248-967-4301
Mailing address:
  • Phone: 248-967-4310
  • Fax: 248-967-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401009027
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: