Healthcare Provider Details

I. General information

NPI: 1275698102
Provider Name (Legal Business Name): KERRY ANN FAGAN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 HAMPTON ST
AUBURN MA
01501-2584
US

IV. Provider business mailing address

250 HAMPTON ST
AUBURN MA
01501-2584
US

V. Phone/Fax

Practice location:
  • Phone: 508-832-4101
  • Fax: 508-842-4209
Mailing address:
  • Phone: 508-832-4101
  • Fax: 508-842-4209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1021091
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: