Provider Demographics
NPI:1528898863
Name:FAIRCHILD, MAKENZIE SHAE
Entity type:Individual
Prefix:MRS
First Name:MAKENZIE
Middle Name:SHAE
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAKENZIE
Other - Middle Name:S
Other - Last Name:DEWITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 W 45TH PL
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-2379
Mailing Address - Country:US
Mailing Address - Phone:918-859-4422
Mailing Address - Fax:
Practice Address - Street 1:6316 E 102ND ST # 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-7061
Practice Address - Country:US
Practice Address - Phone:918-221-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health