Healthcare Provider Details

I. General information

NPI: 1922308469
Provider Name (Legal Business Name): MICHAEL SEAN FAGEN MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 36TH AVE NW STE 101
NORMAN OK
73072-4743
US

IV. Provider business mailing address

448 36TH AVE NW STE 101
NORMAN OK
73072-4743
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-9905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number06990
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: