Healthcare Provider Details

I. General information

NPI: 1881124964
Provider Name (Legal Business Name): RICK K FAGAN LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 WALL ST STE 200
O FALLON IL
62269-1959
US

IV. Provider business mailing address

785 WALL ST
O FALLON IL
62269-1959
US

V. Phone/Fax

Practice location:
  • Phone: 618-367-2194
  • Fax:
Mailing address:
  • Phone: 618-367-2194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180011014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: