Provider Demographics
NPI:1174762058
Name:MARK FAIRFIELD, LCSW, BCD, A LICENSED CLINICAL SOCIAL WORK CORPORATION
Entity type:Organization
Organization Name:MARK FAIRFIELD, LCSW, BCD, A LICENSED CLINICAL SOCIAL WORK CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-339-0609
Mailing Address - Street 1:612 N SEPULVEDA BLVD
Mailing Address - Street 2:STE. 3
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-2175
Mailing Address - Country:US
Mailing Address - Phone:310-339-0609
Mailing Address - Fax:877-768-2272
Practice Address - Street 1:612 N SEPULVEDA BLVD
Practice Address - Street 2:STE. 3
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-2175
Practice Address - Country:US
Practice Address - Phone:310-339-0609
Practice Address - Fax:877-768-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS19969251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health