Provider Demographics
NPI:1902065030
Name:FAIRCLOUGH, CASSANDRA (MSW, CSW)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:FAIRCLOUGH
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9263 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6571
Mailing Address - Country:US
Mailing Address - Phone:801-566-0749
Mailing Address - Fax:
Practice Address - Street 1:9263 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6571
Practice Address - Country:US
Practice Address - Phone:801-566-0749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6289854-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker