Provider Demographics
NPI:1538304779
Name:FAIRCLOTH, MINDY SMATHERS (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:SMATHERS
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CREEK BANK CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3979
Mailing Address - Country:US
Mailing Address - Phone:919-325-2963
Mailing Address - Fax:
Practice Address - Street 1:48 KYLE DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-7535
Practice Address - Country:US
Practice Address - Phone:919-359-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist