Provider Demographics
NPI:1720010382
Name:FAIRCHILD, LINDA KAY (OTR/L)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:KAY
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1696 7TH STR. NW
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313
Mailing Address - Country:US
Mailing Address - Phone:763-682-1223
Mailing Address - Fax:763-682-1668
Practice Address - Street 1:1696 7TH ST NW
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-5050
Practice Address - Country:US
Practice Address - Phone:763-274-1070
Practice Address - Fax:763-274-1071
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100400225X00000X
MN810345-1-WS320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN172360800Medicaid
MN218986-4-AFCOtherADULT FOSTER CARE
MN810345-1-WSOtherHOME AND COMMUNITY BASED