Provider Demographics
NPI:1407738180
Name:FAIRCLOTH, PAMELA KATHLEEN
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:KATHLEEN
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 CHAMPS CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-9355
Mailing Address - Country:US
Mailing Address - Phone:910-584-6556
Mailing Address - Fax:
Practice Address - Street 1:632 W PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2512
Practice Address - Country:US
Practice Address - Phone:910-875-5590
Practice Address - Fax:910-875-5008
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0225721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty