Individual
AMANDA FAIRBANKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OTR/L
Contact information
Practice address
1050 4 MILE RD NW, GRAND RAPIDS, MI 49544-1505
(616) 685-7073
Mailing address
7941 KINMONT CT, JENISON, MI 49428-9109
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
5201008519
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5201008519
OCCUPATIONAL THERAPY STATE LICENSURE
MI
Enumeration date
07/10/2018
Last updated
07/10/2018
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