Healthcare Provider Details

I. General information

NPI: 1730805110
Provider Name (Legal Business Name): LEIGH FAGERSTROM LCSW, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BAYARD ST
NEW BRUNSWICK NJ
08901-2389
US

IV. Provider business mailing address

4 AUER CT STE G
EAST BRUNSWICK NJ
08816-5826
US

V. Phone/Fax

Practice location:
  • Phone: 732-847-2869
  • Fax:
Mailing address:
  • Phone: 732-672-8754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: