Provider Demographics
NPI:1679911259
Name:FAIRCLOUGH, MARIA TERESA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:TERESA
Last Name:FAIRCLOUGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11101 COLVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3708
Mailing Address - Country:US
Mailing Address - Phone:505-227-5459
Mailing Address - Fax:575-623-1240
Practice Address - Street 1:2317 N SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6429
Practice Address - Country:US
Practice Address - Phone:505-227-5459
Practice Address - Fax:575-623-1240
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0115481101YA0400X
NMM-085761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)