Provider Demographics
NPI:1225424286
Name:FAIRCHILD, KIMBERLY (LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1472 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:ARKDALE
Mailing Address - State:WI
Mailing Address - Zip Code:54613-9624
Mailing Address - Country:US
Mailing Address - Phone:920-889-9388
Mailing Address - Fax:
Practice Address - Street 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7129-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100043623Medicaid
WIK401235342Medicaid