Provider Demographics
NPI:1508316415
Name:FAIRLEY, MAURICE JR
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:FAIRLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5597
Mailing Address - Country:US
Mailing Address - Phone:919-280-6550
Mailing Address - Fax:
Practice Address - Street 1:500 BENSON RD
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3947
Practice Address - Country:US
Practice Address - Phone:984-233-1471
Practice Address - Fax:984-272-4865
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12545101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional