Healthcare Provider Details

I. General information

NPI: 1851594899
Provider Name (Legal Business Name): SUSAN MICHELLE FAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 CENTER STREET SUITE B
WALLINGFORD CT
06492
US

IV. Provider business mailing address

89 S RIDGELAND RD
WALLINGFORD CT
06492-2921
US

V. Phone/Fax

Practice location:
  • Phone: 203-284-3467
  • Fax:
Mailing address:
  • Phone: 203-265-9998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006222
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: