Healthcare Provider Details

I. General information

NPI: 1205075801
Provider Name (Legal Business Name): BJM FAIRY GODMOTHER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 02/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6170 SNI A BAR RD
KANSAS CITY MO
64129-1955
US

IV. Provider business mailing address

6170 SNI A BAR RD
KANSAS CITY MO
64129-1955
US

V. Phone/Fax

Practice location:
  • Phone: 913-220-2435
  • Fax: 913-220-2435
Mailing address:
  • Phone: 913-220-2435
  • Fax: 913-220-2435

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: BARBARA JEAN MARVIN
Title or Position: PRESIDENT
Credential: LCSW
Phone: 913-220-2435