Healthcare Provider Details

I. General information

NPI: 1194002873
Provider Name (Legal Business Name): MR. RONALD WALTER FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5508 RIDGEWAY CT
WESTLAKE VILLAGE CA
91362-5266
US

IV. Provider business mailing address

5508 RIDGEWAY CT
WESTLAKE VILLAGE CA
91362-5266
US

V. Phone/Fax

Practice location:
  • Phone: 818-665-9555
  • Fax: 888-656-4789
Mailing address:
  • Phone: 818-665-9555
  • Fax: 888-656-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 39067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: