Provider Demographics
NPI:1316689771
Name:FAIRCLOUGH, KERRIE-ANN T (LMSW)
Entity type:Individual
Prefix:
First Name:KERRIE-ANN
Middle Name:T
Last Name:FAIRCLOUGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 CHRISTIE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550
Mailing Address - Country:US
Mailing Address - Phone:516-353-1997
Mailing Address - Fax:
Practice Address - Street 1:652 CHRISTIE ST
Practice Address - Street 2:
Practice Address - City:SOUTH HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550
Practice Address - Country:US
Practice Address - Phone:516-353-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101105-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker