Provider Demographics
NPI:1205075801
Name:BJM FAIRY GODMOTHER LLC
Entity type:Organization
Organization Name:BJM FAIRY GODMOTHER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:913-220-2435
Mailing Address - Street 1:6170 SNI A BAR RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64129-1955
Mailing Address - Country:US
Mailing Address - Phone:913-220-2435
Mailing Address - Fax:913-220-2435
Practice Address - Street 1:6170 SNI A BAR RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64129-1955
Practice Address - Country:US
Practice Address - Phone:913-220-2435
Practice Address - Fax:913-220-2435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty