Healthcare Provider Details

I. General information

NPI: 1306370887
Provider Name (Legal Business Name): SHAWNA-GAYE FAGON LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 CARPENTER DR SUITE 400
ATLANTA GA
30328-4931
US

IV. Provider business mailing address

119 SHADOWHILL LN
LOGANVILLE GA
30052-8289
US

V. Phone/Fax

Practice location:
  • Phone: 678-460-0345
  • Fax:
Mailing address:
  • Phone: 404-825-9705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC009436
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: