Basic Information
| Provider Information | |||||||||
| NPI: | 1104271501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRCLOUGH | ||||||||
| FirstName: | KAHIYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5575 S SEMORAN BLVD STE 7 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328221781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443316451 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2218 MAHAN DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323086127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503206555 | ||||||||
| FaxNumber: | 8888734610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2016 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 019974800 | 05 | FL | MEDICAID |