Provider Demographics
NPI:1619359924
Name:BOSTICK-FAIRLEY, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:BOSTICK-FAIRLEY
Suffix:
Gender:F
Credentials:
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 2425
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28353-2425
Mailing Address - Country:US
Mailing Address - Phone:910-361-4522
Mailing Address - Fax:
Practice Address - Street 1:501A WESTWOOD WAY
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-3459
Practice Address - Country:US
Practice Address - Phone:910-361-4522
Practice Address - Fax:910-361-4759
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0109651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical