Healthcare Provider Details

I. General information

NPI: 1023771540
Provider Name (Legal Business Name): TRICIA HOPE FAGAN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E JAMES LEE BLVD
CRESTVIEW FL
32539-3126
US

IV. Provider business mailing address

1192 JENNINGS TRCE
HOLT FL
32564-9660
US

V. Phone/Fax

Practice location:
  • Phone: 506-894-6878
  • Fax:
Mailing address:
  • Phone: 850-375-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH17703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: