Provider Demographics
NPI:1619344082
Name:FAIRCHILD, KATHLEEN (BCBA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MCKENNAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7903
Mailing Address - Country:US
Mailing Address - Phone:507-995-7316
Mailing Address - Fax:
Practice Address - Street 1:111 MACKENAN DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7903
Practice Address - Country:US
Practice Address - Phone:507-995-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-12-10286103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst