Healthcare Provider Details

I. General information

NPI: 1053345553
Provider Name (Legal Business Name): CLIFFORD RAYMOND FAGAN LCSW CCM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W AIRPORT FWY STE 1100
IRVING TX
75062-6312
US

IV. Provider business mailing address

800 W AIRPORT FWY STE 1100
IRVING TX
75062-6312
US

V. Phone/Fax

Practice location:
  • Phone: 214-704-5879
  • Fax: 888-974-1492
Mailing address:
  • Phone: 214-704-5879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number31107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: