Healthcare Provider Details

I. General information

NPI: 1578953915
Provider Name (Legal Business Name): KATHARINE FAGAN-NELSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

1405 HOVEY AVE
NORMAL IL
61761-3324
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-7267
  • Fax:
Mailing address:
  • Phone: 309-826-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149009316
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: