Healthcare Provider Details

I. General information

NPI: 1679911259
Provider Name (Legal Business Name): MARIA TERESA FAIRCLOUGH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 03/03/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 N SHERMAN AVE
ROSWELL NM
88201-6429
US

IV. Provider business mailing address

11101 COLVILLE RD SE
ALBUQUERQUE NM
87123-3708
US

V. Phone/Fax

Practice location:
  • Phone: 505-227-5459
  • Fax: 575-623-1240
Mailing address:
  • Phone: 505-227-5459
  • Fax: 575-623-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0115481
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08576
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: