Healthcare Provider Details

I. General information

NPI: 1417558065
Provider Name (Legal Business Name): ELIZABETH FAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E 91ST ST APT 4C
NEW YORK NY
10128-1659
US

IV. Provider business mailing address

108 E 91ST ST APT 4C
NEW YORK NY
10128-1659
US

V. Phone/Fax

Practice location:
  • Phone: 917-208-3907
  • Fax:
Mailing address:
  • Phone: 917-208-3907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR038388
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: