Healthcare Provider Details

I. General information

NPI: 1346858024
Provider Name (Legal Business Name): FAIRCLOUGH CONSULTING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9224 TUDOR PARK PL
LAS VEGAS NV
89145-8726
US

IV. Provider business mailing address

9224 TUDOR PARK PL
LAS VEGAS NV
89145-8726
US

V. Phone/Fax

Practice location:
  • Phone: 561-309-3507
  • Fax:
Mailing address:
  • Phone: 561-309-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH ANTHONY FAIRCLOUGH JR.
Title or Position: CEO
Credential: LMHC
Phone: 561-309-3507