Healthcare Provider Details

I. General information

NPI: 1114568508
Provider Name (Legal Business Name): LEIGH ANNE FAGIN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 UNIVERSITY CT
MONTGOMERY AL
36117-8016
US

IV. Provider business mailing address

7125 UNIVERSITY CT
MONTGOMERY AL
36117-8016
US

V. Phone/Fax

Practice location:
  • Phone: 334-239-2622
  • Fax:
Mailing address:
  • Phone: 334-239-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4365C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: