Provider Demographics
NPI:1730661331
Name:FAIR PARK COUNSELING PLLC
Entity Type:Organization
Organization Name:FAIR PARK COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:662-760-0052
Mailing Address - Street 1:210 E MAIN ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-4017
Mailing Address - Country:US
Mailing Address - Phone:662-760-0052
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST STE 2C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4017
Practice Address - Country:US
Practice Address - Phone:662-760-0052
Practice Address - Fax:662-495-4080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty