Healthcare Provider Details

I. General information

NPI: 1629157615
Provider Name (Legal Business Name): ALICIA MARY FAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 NORTH MAIN STREET STE 2C
SOUTHINGTON CT
06489
US

IV. Provider business mailing address

51 NORTH MAIN STREET STE 2C
SOUTHINGTON CT
06489
US

V. Phone/Fax

Practice location:
  • Phone: 860-621-2280
  • Fax: 860-628-0219
Mailing address:
  • Phone: 860-621-2280
  • Fax: 860-628-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000422
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000618
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: