Healthcare Provider Details

I. General information

NPI: 1457678096
Provider Name (Legal Business Name): ELIZABETH FAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE
AURORA CO
80045-7106
US

IV. Provider business mailing address

1655 S EMERSON ST
DENVER CO
80210-2729
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-4625
  • Fax:
Mailing address:
  • Phone: 858-220-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number448
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: