Provider Demographics
NPI:1841385291
Name:FAIRCLOTH, MIAH MICHEL (BS)
Entity Type:Individual
Prefix:
First Name:MIAH
Middle Name:MICHEL
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W. 23RD STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401
Mailing Address - Country:US
Mailing Address - Phone:850-747-5411
Mailing Address - Fax:850-747-5583
Practice Address - Street 1:700 W. 23RD STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401
Practice Address - Country:US
Practice Address - Phone:850-747-5411
Practice Address - Fax:850-747-5583
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker