Healthcare Provider Details

I. General information

NPI: 1881725455
Provider Name (Legal Business Name): SUSAN G. FAGO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 CONNECTICUT AVE NW STE 401
WASHINGTON DC
20036-1124
US

IV. Provider business mailing address

1882 COLUMBIA RD NW APT 202
WASHINGTON DC
20009-5137
US

V. Phone/Fax

Practice location:
  • Phone: 202-441-7240
  • Fax:
Mailing address:
  • Phone: 202-483-8148
  • Fax: 301-927-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50078121
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05362
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: