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General NPI Number Information
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NPI Number | 1366657827
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Entity Type | Individual
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Provider Name | RONALD T FAIRCLOTH LPC, LISAC
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Gender | Male
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 3127 W GIBSON LN
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City | PHOENIX
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State | AZ
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Zip | 85009-6212
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Country | US
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Telephone | 602-876-1715
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Fax |
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Provider Business Mailing Address
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Address Line | 1018 E OSBORN RD UNIT F
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City | PHOENIX
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State | AZ
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Zip | 85014-5295
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Country | US
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Telephone | 602-234-1990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LISAC-11421
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC-11915
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License Number State | AZ
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