Healthcare Provider Details

I. General information

NPI: 1497997860
Provider Name (Legal Business Name): KRISTIN J FAIREY MA LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8205 SPAIN RD NE SUITE 106
ALBUQUERQUE NM
87109-3179
US

IV. Provider business mailing address

8205 SPAIN RD NE SUITE 106
ALBUQUERQUE NM
87109-3179
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-0300
  • Fax: 505-856-7946
Mailing address:
  • Phone: 505-856-0300
  • Fax: 505-856-7946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0113581
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0100081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: