Provider Demographics
NPI:1790568129
Name:FAIRCLOTH, CASSONDRA DANIELLE (MA, LCMHCA)
Entity Type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:DANIELLE
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:MA, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2095 PINEY MOUNTAIN RD APT A
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-7803
Mailing Address - Country:US
Mailing Address - Phone:336-813-8523
Mailing Address - Fax:
Practice Address - Street 1:227 W MOREHEAD ST STE 2
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3872
Practice Address - Country:US
Practice Address - Phone:336-908-3927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19129101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health