Provider Demographics
NPI:1790812485
Name:FAIRWEATHER, SCOTT D (LISW-CP, CAC-I)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:FAIRWEATHER
Suffix:
Gender:M
Credentials:LISW-CP, CAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEDICAL PARK
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6894
Mailing Address - Country:US
Mailing Address - Phone:803-434-4300
Mailing Address - Fax:803-434-4351
Practice Address - Street 1:15 MEDICAL PARK
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6894
Practice Address - Country:US
Practice Address - Phone:803-434-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1005207101YA0400X
101YM0800X
SC88661041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health