Provider Demographics
NPI:1346858024
Name:FAIRCLOUGH CONSULTING SERVICES, LLC
Entity Type:Organization
Organization Name:FAIRCLOUGH CONSULTING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:FAIRCLOUGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMHC
Authorized Official - Phone:561-309-3507
Mailing Address - Street 1:9224 TUDOR PARK PL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-8726
Mailing Address - Country:US
Mailing Address - Phone:561-309-3507
Mailing Address - Fax:
Practice Address - Street 1:9224 TUDOR PARK PL
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8726
Practice Address - Country:US
Practice Address - Phone:561-309-3507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1831563097Medicaid