Basic Information
| Provider Information | |||||||||
| NPI: | 1619020187 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIR | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282134502 | ||||||||
| FaxNumber: | 8286811577 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 BILTMORE AVE | ||||||||
| Address2: | SUITE G276.10 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282134502 | ||||||||
| FaxNumber: | 8286811577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 4950 | SC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 10660 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | PC 1319 | 05 | SC | MEDICAID |