Healthcare Provider Details

I. General information

NPI: 1497954580
Provider Name (Legal Business Name): PATRICK L FAGAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 PEARL ST SUITE 3
EUGENE OR
97401-3642
US

IV. Provider business mailing address

980 BOBOLINK AVE
EUGENE OR
97404-1513
US

V. Phone/Fax

Practice location:
  • Phone: 541-968-7424
  • Fax:
Mailing address:
  • Phone: 541-607-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: