Healthcare Provider Details

I. General information

NPI: 1669013843
Provider Name (Legal Business Name): MR. BRIAN J FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 05/14/2022
Certification Date: 05/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W CHICAGO AVE
CHICAGO IL
60654-5106
US

IV. Provider business mailing address

990 GROVE ST STE 303
EVANSTON IL
60201-6513
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-6545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: