Provider Demographics
NPI:1609111020
Name:FAIRHAVENS COUNSELING AND COMMUNITY SERVICES
Entity Type:Organization
Organization Name:FAIRHAVENS COUNSELING AND COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, EDS, LPC, NCC
Authorized Official - Phone:678-778-4342
Mailing Address - Street 1:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-1311
Mailing Address - Country:US
Mailing Address - Phone:678-778-4342
Mailing Address - Fax:
Practice Address - Street 1:1401 CRAG BURN LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-6907
Practice Address - Country:US
Practice Address - Phone:678-778-4342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health