Provider Demographics
NPI:1447557111
Name:FAIRCHILD, KELLY J (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 EAGLE RUN DR NE
Mailing Address - Street 2:STE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7070
Mailing Address - Country:US
Mailing Address - Phone:616-365-8920
Mailing Address - Fax:616-365-8971
Practice Address - Street 1:3351 EAGLE RUN DR NE
Practice Address - Street 2:STE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7070
Practice Address - Country:US
Practice Address - Phone:616-365-8920
Practice Address - Fax:616-365-8971
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010585521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical