Provider Demographics
NPI:1225469513
Name:FAIRCLOTH, ASHLEY MICHELE TANKERSLEY (DPT)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:MICHELE TANKERSLEY
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 NOTTOWAY DR
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-3804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1796 W CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2955
Practice Address - Country:US
Practice Address - Phone:985-626-1671
Practice Address - Fax:985-624-4984
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA08611OtherLICENSE TO PRACTICE PHYSICAL THERAPY