Healthcare Provider Details

I. General information

NPI: 1730626011
Provider Name (Legal Business Name): MARC FAGAN PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 N RAVENSWOOD AVE.
CHICAGO IL
60613
US

IV. Provider business mailing address

1335 DEERFIELD RD
DEERFIELD IL
60015
US

V. Phone/Fax

Practice location:
  • Phone: 773-572-5402
  • Fax:
Mailing address:
  • Phone: 847-651-2493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.006654
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: