Provider Demographics
NPI:1912281031
Name:FAIRWAY COUNSELING AGENCY, INC.
Entity type:Organization
Organization Name:FAIRWAY COUNSELING AGENCY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEASIDE HC BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:GEMMALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-234-8280
Mailing Address - Street 1:101 FEU FOLLET RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4234
Mailing Address - Country:US
Mailing Address - Phone:337-234-8455
Mailing Address - Fax:318-449-4472
Practice Address - Street 1:710 VERSAILLES BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2351
Practice Address - Country:US
Practice Address - Phone:318-449-4474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1803871Medicaid