Healthcare Provider Details

I. General information

NPI: 1518671221
Provider Name (Legal Business Name): SANDRA FAIRBANKS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 GENESSEE ST STE 502
KANSAS CITY MO
64102-1085
US

IV. Provider business mailing address

1608 S HARRIS AVE
INDEPENDENCE MO
64052-3730
US

V. Phone/Fax

Practice location:
  • Phone: 816-699-0103
  • Fax:
Mailing address:
  • Phone: 816-699-0103
  • Fax: 816-503-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024042652
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: