Basic Information
| Provider Information | |||||||||
| NPI: | 1164620043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIRCHILD | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | LESLIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAIRCHILD | ||||||||
| OtherFirstName: | JESSE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH EAST | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219013920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438774044 | ||||||||
| FaxNumber: | 4435057065 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S MAIN ST | ||||||||
| Address2: | SUITE 101B | ||||||||
| City: | NORTH EAST | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219013920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438774044 | ||||||||
| FaxNumber: | 4435057065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 07/05/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LC2857 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.