Healthcare Provider Details

I. General information

NPI: 1740773175
Provider Name (Legal Business Name): JOSEPH MICHAEL FAGAN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4424 E BASELINE RD APT 2067
PHOENIX AZ
85042-7440
US

IV. Provider business mailing address

4424 E BASELINE RD APT 2067
PHOENIX AZ
85042-7440
US

V. Phone/Fax

Practice location:
  • Phone: 602-510-4662
  • Fax:
Mailing address:
  • Phone: 602-510-4662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-16158
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: