Provider Demographics
NPI:1619020187
Name:FAIR, MARLA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:FAIR
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-213-4502
Mailing Address - Fax:828-681-1577
Practice Address - Street 1:501 BILTMORE AVE
Practice Address - Street 2:SUITE G276.10
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4601
Practice Address - Country:US
Practice Address - Phone:828-213-4502
Practice Address - Fax:828-681-1577
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC4950101YP2500X
NC10660101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC 1319Medicaid