Provider Demographics
NPI:1396286258
Name:FAIRBAIRN, KALEY SUZANNE (LMSW)
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:SUZANNE
Last Name:FAIRBAIRN
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 1:1960 RUPERT ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2861
Mailing Address - Country:US
Mailing Address - Phone:616-540-6010
Mailing Address - Fax:
Practice Address - Street 1:550 CASCADE WEST PKWY SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2137
Practice Address - Country:US
Practice Address - Phone:616-930-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-12
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098978104100000X
MI6801108273104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker