Healthcare Provider Details

I. General information

NPI: 1023568961
Provider Name (Legal Business Name): TERESE FAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 S MAIN ST SUITE 107
WEST HARTFORD CT
06107-2441
US

IV. Provider business mailing address

1131 TOLLAND TPKE UNIT 258
MANCHESTER CT
06042-1679
US

V. Phone/Fax

Practice location:
  • Phone: 860-778-3304
  • Fax:
Mailing address:
  • Phone: 860-778-3304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number008738
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: