Healthcare Provider Details

I. General information

NPI: 1912572660
Provider Name (Legal Business Name): TIFFANY SIMONE FAGAN LMHC, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. TIFFANY SIMONE RAMBERG

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

IV. Provider business mailing address

PO BOX 637764
CINCINNATI OH
45263-7764
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-0000
  • Fax:
Mailing address:
  • Phone: 317-880-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003186A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: