Healthcare Provider Details

I. General information

NPI: 1487283685
Provider Name (Legal Business Name): MIRIAM FAGAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SMITH RANCH RD
SAN RAFAEL CA
94903-1939
US

IV. Provider business mailing address

775 E BLITHEDALE AVE # 141
MILL VALLEY CA
94941-1554
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-3003
  • Fax:
Mailing address:
  • Phone: 415-569-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: