Provider Demographics
NPI:1215509492
Name:FAIRCLOTH, CHARLES JOSEPH
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 KEVIN RD
Mailing Address - Street 2:
Mailing Address - City:APALACHICOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32320-1214
Mailing Address - Country:US
Mailing Address - Phone:404-301-9914
Mailing Address - Fax:
Practice Address - Street 1:113 KEVIN RD
Practice Address - Street 2:
Practice Address - City:APALACHICOLA
Practice Address - State:FL
Practice Address - Zip Code:32320-1214
Practice Address - Country:US
Practice Address - Phone:404-301-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health