Healthcare Provider Details

I. General information

NPI: 1720822117
Provider Name (Legal Business Name): FAIRWATER COUNSELING AND CONSULTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6195 PINECREST DRIVE SW
COVINGTON GA
30014
US

IV. Provider business mailing address

6195 PINECREST DR SW
COVINGTON GA
30014-3560
US

V. Phone/Fax

Practice location:
  • Phone: 404-490-3277
  • Fax:
Mailing address:
  • Phone: 404-490-3277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SONJA CRAWLEY
Title or Position: MANAGER
Credential:
Phone: 404-490-3277