Provider Demographics
NPI:1831898352
Name:FAIRBOURNE GROUP
Entity type:Organization
Organization Name:FAIRBOURNE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALT
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:801-608-1934
Mailing Address - Street 1:145 E 900 S STE 6
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4241
Mailing Address - Country:US
Mailing Address - Phone:385-722-4505
Mailing Address - Fax:
Practice Address - Street 1:145 E 900 S STE 6
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4241
Practice Address - Country:US
Practice Address - Phone:385-722-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty