Healthcare Provider Details

I. General information

NPI: 1043247489
Provider Name (Legal Business Name): SUSAN FAGAN MORAN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 WESTFIELD ST
WEST SPRINGFIELD MA
01089-3878
US

IV. Provider business mailing address

41 UNITY AVE
BELMONT MA
02478-3671
US

V. Phone/Fax

Practice location:
  • Phone: 413-592-1980
  • Fax: 413-439-0096
Mailing address:
  • Phone: 617-489-5987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH3935-CC
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: