Healthcare Provider Details

I. General information

NPI: 1679839997
Provider Name (Legal Business Name): STEPHANIE A FAGAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 N MAIN STREET
DAYVILLE CT
06241-2170
US

IV. Provider business mailing address

4115 WISCONSIN AVE NW APT. 501
WASHINGTON DC
20016
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-2020
  • Fax: 860-779-5437
Mailing address:
  • Phone: 347-254-4668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50081357
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1237
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: