Healthcare Provider Details

I. General information

NPI: 1154777803
Provider Name (Legal Business Name): DOUGLAS BRIAN FAGEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4759 RESERVOIR RD NW
WASHINGTON DC
20007-1921
US

IV. Provider business mailing address

4759 RESERVOIR RD NW
WASHINGTON DC
20007-1921
US

V. Phone/Fax

Practice location:
  • Phone: 202-944-3071
  • Fax: 202-454-2292
Mailing address:
  • Phone: 202-944-3071
  • Fax: 202-454-2292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1000067
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: