Provider Demographics
NPI:1497997860
Name:FAIREY, KRISTIN J (MA LPCC)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:J
Last Name:FAIREY
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 SPAIN RD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3179
Mailing Address - Country:US
Mailing Address - Phone:505-856-0300
Mailing Address - Fax:505-856-7946
Practice Address - Street 1:8205 SPAIN RD NE
Practice Address - Street 2:SUITE 106
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3179
Practice Address - Country:US
Practice Address - Phone:505-856-0300
Practice Address - Fax:505-856-7946
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0113581101YA0400X
NM0100081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48625225Medicaid