Healthcare Provider Details

I. General information

NPI: 1043468556
Provider Name (Legal Business Name): SUSAN MARIE FAGAN L.P.C., R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 WOODCREST EXECUTIVE DR SUITE 110
SAINT LOUIS MO
63141-5001
US

IV. Provider business mailing address

10820 SUNSET OFFICE DR SUITE 122
SAINT LOUIS MO
63127-1016
US

V. Phone/Fax

Practice location:
  • Phone: 314-275-8599
  • Fax:
Mailing address:
  • Phone: 314-954-6553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2004032923
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: