Healthcare Provider Details

I. General information

NPI: 1568932804
Provider Name (Legal Business Name): FAIRCLOUGH BEHAVIOR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3852 MIRANDA CT
SUWANEE GA
30024-8670
US

IV. Provider business mailing address

3852 MIRANDA CT
SUWANEE GA
30024-8670
US

V. Phone/Fax

Practice location:
  • Phone: 770-608-7317
  • Fax:
Mailing address:
  • Phone: 770-608-7317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAUN PAUL FAIRCLOUGH
Title or Position: OWNER/BCBA
Credential: BCBA
Phone: 770-608-7317