Provider Demographics
NPI:1003303694
Name:FAIRCHILD, KYLE (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:M
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 W 3600 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8423
Mailing Address - Country:US
Mailing Address - Phone:208-670-1018
Mailing Address - Fax:
Practice Address - Street 1:451 E BISHOP FEDERAL LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2357
Practice Address - Country:US
Practice Address - Phone:801-487-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9379311-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist