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NPI Code Detail

MEDICARE: KRISTYN ANN FAIRCLOTH LCSW

MEDICARE: KRISTYN ANN FAIRCLOTH LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker18824FL

General Provider Information

NPI Number : 1083370704
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTYN ANN FAIRCLOTH LCSW
Provider Business Mailing Address
First Line : 216 SE CORRECTIONS WAY
Second Line :
City : LAKE CITY
State : FL
Zip : 32025-2013
Country : US
Telephone Number : 386-292-7198
Fax Number :
Provider Business Practice Location Address
First Line : 216 SE CORRECTIONS WAY
Second Line :
City : LAKE CITY
State : FL
Zip : 32025-2013
Country : US
Telephone Number : 386-292-7198
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/17/2021
Last Update Date : 11/17/2021

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