MEDICARE: KALEY FAIRBAIRN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1033870829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALEY FAIRBAIRN LLC

Provider Business Mailing Address
First Line	:	1960 RUPERT ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-2861
Country	:	US
Telephone Number	:	616-540-6010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 RUPERT ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-2861
Country	:	US
Telephone Number	:	616-540-6010
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KALEY FAIRBAIRN
Credential	:	LMSW
Telephone Number	:	616-540-6010

Provider Enumeration Date	:	01/04/2022
Last Update Date	:	01/04/2022

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