Provider Demographics
NPI:1487196788
Name:BARRON, FAYETTA (LISW-S, LICDC)
Entity Type:Individual
Prefix:MRS
First Name:FAYETTA
Middle Name:
Last Name:BARRON
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-5037
Mailing Address - Country:US
Mailing Address - Phone:937-281-4673
Mailing Address - Fax:937-342-4242
Practice Address - Street 1:113 JAMES DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5219
Practice Address - Country:US
Practice Address - Phone:937-241-9230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18013291041C0700X
OHS1501079104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical