Healthcare Provider Details

I. General information

NPI: 1154754943
Provider Name (Legal Business Name): ALYSSA L FAGAN-CLARK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20440 N 27TH AVE
PHOENIX AZ
85027-3240
US

IV. Provider business mailing address

7500 N DREAMY DRAW DR STE 145
PHOENIX AZ
85020-4668
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-4545
  • Fax: 602-910-2949
Mailing address:
  • Phone: 480-886-2454
  • Fax: 602-409-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-21945
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: