Healthcare Provider Details

I. General information

NPI: 1114702081
Provider Name (Legal Business Name): CHARTYISE FAGAN M.A., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5726 SOUTHWYCK BLVD
TOLEDO OH
43614-1559
US

IV. Provider business mailing address

722 FERNWOOD AVE
TOLEDO OH
43604-8032
US

V. Phone/Fax

Practice location:
  • Phone: 419-705-8597
  • Fax:
Mailing address:
  • Phone: 419-343-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2606106
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: