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General NPI Number Information
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NPI Number | 1598447732
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Entity Type | Individual
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Provider Name | CASSANDRA LYN FAIRBOTHAM LMSW
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Gender | Female
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Dates
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Enumeration Date | 08/07/2023
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Last Update Date | 11/07/2025
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Provider Practice Location Address
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Address Line | 650 S WAVERLY RD
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City | HOLLAND
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State | MI
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Zip | 49423-9121
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Country | US
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Telephone | 616-591-9000
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Fax | 616-432-3059
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Provider Business Mailing Address
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Address Line | 4191 E VALLEY DR
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City | HUDSONVILLE
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State | MI
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Zip | 49426-7465
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Country | US
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Telephone | 616-312-6822
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801120796
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License Number State | MI
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