Healthcare Provider Details

I. General information

NPI: 1831898352
Provider Name (Legal Business Name): FAIRBOURNE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 E 900 S STE 6
SALT LAKE CITY UT
84111-4241
US

IV. Provider business mailing address

145 E 900 S STE 6
SALT LAKE CITY UT
84111-4241
US

V. Phone/Fax

Practice location:
  • Phone: 385-722-4505
  • Fax:
Mailing address:
  • Phone: 385-722-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CAITLIN GALT
Title or Position: OWNER/DIRECTOR
Credential: CMHC
Phone: 801-608-1934