Healthcare Provider Details

I. General information

NPI: 1194540096
Provider Name (Legal Business Name): BETSY FAGIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 GLENDORA AVE APT 1
LONG BEACH CA
90803-3510
US

IV. Provider business mailing address

266 GLENDORA AVE APT 1
LONG BEACH CA
90803-3510
US

V. Phone/Fax

Practice location:
  • Phone: 562-233-4210
  • Fax:
Mailing address:
  • Phone: 562-233-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW79516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: