Provider Demographics
NPI:1245398668
Name:FAIRCHILD, CONNIE M (MA LPC CAC I)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:M
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:MA LPC CAC I
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:FAIRCHILD
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2687
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80901-2687
Mailing Address - Country:US
Mailing Address - Phone:719-291-5623
Mailing Address - Fax:219-473-4066
Practice Address - Street 1:315 E DALE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1102
Practice Address - Country:US
Practice Address - Phone:719-291-5623
Practice Address - Fax:219-473-4066
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5708CAC101YA0400X
COLPC1385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)