Provider Demographics
NPI:1366657827
Name:FAIRCLOTH, RONALD T (LPC, LISAC)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:T
Last Name:FAIRCLOTH
Suffix:
Gender:M
Credentials:LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 E OSBORN RD
Mailing Address - Street 2:UNIT F
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5295
Mailing Address - Country:US
Mailing Address - Phone:602-234-1990
Mailing Address - Fax:
Practice Address - Street 1:3127 W GIBSON LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-6212
Practice Address - Country:US
Practice Address - Phone:602-876-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11421101YA0400X
AZLPC-11915101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional