Healthcare Provider Details

I. General information

NPI: 1770179152
Provider Name (Legal Business Name): EMILY FAGAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 E BURNSIDE ST
PORTLAND OR
97214-1831
US

IV. Provider business mailing address

7515 FALCON CREST DR # 200
REDMOND OR
97756-5014
US

V. Phone/Fax

Practice location:
  • Phone: 503-953-0310
  • Fax:
Mailing address:
  • Phone: 541-904-5216
  • Fax: 541-527-4347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC7728
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: