Healthcare Provider Details

I. General information

NPI: 1235262619
Provider Name (Legal Business Name): KELLY ANNE FAGAN-DYER LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 N MAIN ST
WASHINGTON PA
15301-4349
US

IV. Provider business mailing address

760 SARA DR
WASHINGTON PA
15301-2828
US

V. Phone/Fax

Practice location:
  • Phone: 724-223-7803
  • Fax: 724-223-7804
Mailing address:
  • Phone: 724-223-7803
  • Fax: 724-223-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberSW125236
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: