Provider Demographics
NPI:1346742988
Name:FAIRCLOTH, JOHN WILLIAM (EDD, SLP-CCC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:EDD, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23324-3527
Mailing Address - Country:US
Mailing Address - Phone:757-494-7600
Mailing Address - Fax:757-494-7573
Practice Address - Street 1:2107 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-3527
Practice Address - Country:US
Practice Address - Phone:757-494-7600
Practice Address - Fax:757-494-7573
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202001051235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202001051OtherBOARD OF AUDIOLOGY AND SPEECH PATHOLOGY