=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205282993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DARLENE P. FAIRLEY LPC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2016
-----------------------------------------------------
Last Update Date | 05/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 WAGONER DR SUITE 313
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-273-0625
-----------------------------------------------------
Fax | 910-568-3690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 351 WAGONER DR SUITE 313
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-273-0625
-----------------------------------------------------
Fax | 910-568-3690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DARLENE PATRICIA FAIRLEY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 910-273-0625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------