Healthcare Provider Details

I. General information

NPI: 1063929768
Provider Name (Legal Business Name): TAMARA B FAGAN MA, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E MAIN ST
PICKENS SC
29671-2319
US

IV. Provider business mailing address

309 E MAIN ST
PICKENS SC
29671-2319
US

V. Phone/Fax

Practice location:
  • Phone: 864-898-5800
  • Fax: 864-898-5804
Mailing address:
  • Phone: 864-898-5800
  • Fax: 864-898-5804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11507
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: