Healthcare Provider Details

I. General information

NPI: 1427527407
Provider Name (Legal Business Name): CHARNA FAGAN MA COUNSELING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARNA JONES MA COUNSELING

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S RIDGEWOOD AVE STE 32
SOUTH DAYTONA FL
32119-3073
US

IV. Provider business mailing address

PO BOX 12104
DAYTONA BEACH FL
32120-2104
US

V. Phone/Fax

Practice location:
  • Phone: 863-608-6427
  • Fax:
Mailing address:
  • Phone: 863-608-6427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: