Healthcare Provider Details

I. General information

NPI: 1104093061
Provider Name (Legal Business Name): PAMELA FAGAN M.A., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13923 W WAINWRIGHT DR STE 302
BOISE ID
83713-1969
US

IV. Provider business mailing address

13599 W ELMSPRING ST
BOISE ID
83713-1389
US

V. Phone/Fax

Practice location:
  • Phone: 208-724-8598
  • Fax:
Mailing address:
  • Phone: 208-724-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-4674
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: