MEDICARE: KELLY FAIRCHILD

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	235Z00000X	Speech-Language Pathologist	23189	CA

General Provider Information

NPI Number	:	1801251707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY FAIRCHILD

Provider Business Mailing Address
First Line	:	204 S REEVES DR
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90212-4056
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 S REEVES DR
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90212-4056
Country	:	US
Telephone Number	:	913-486-3775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2015
Last Update Date	:	12/18/2015

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Directions to “ KELLY FAIRCHILD ” Practice Location

Language	Start Address	Practice Location

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