Provider Demographics
NPI:1033595665
Name:FAIRSKY FOUNDATION
Entity Type:Organization
Organization Name:FAIRSKY FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-581-8777
Mailing Address - Street 1:23231 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1361
Mailing Address - Country:US
Mailing Address - Phone:248-581-8777
Mailing Address - Fax:888-975-9374
Practice Address - Street 1:23231 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1361
Practice Address - Country:US
Practice Address - Phone:248-581-8777
Practice Address - Fax:888-975-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICV0058149Medicaid