Healthcare Provider Details

I. General information

NPI: 1326873191
Provider Name (Legal Business Name): CALAH BROOKE FAIRCLOTH HUFFINES MA, LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CALAH BROOKE FAIRCLOTH

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 W 5TH ST
WINSTON SALEM NC
27101-2506
US

IV. Provider business mailing address

2487 SOMERSET PLACE DR
WINSTON SALEM NC
27103-9624
US

V. Phone/Fax

Practice location:
  • Phone: 336-355-8244
  • Fax: 336-546-7630
Mailing address:
  • Phone: 828-514-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA20479
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: