Healthcare Provider Details

I. General information

NPI: 1619683448
Provider Name (Legal Business Name): ALEXA FAGAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24546 KINGSLAND BLVD
KATY TX
77494-3429
US

IV. Provider business mailing address

1699 HERMANN DR UNIT 5134
HOUSTON TX
77004-8137
US

V. Phone/Fax

Practice location:
  • Phone: 832-913-8747
  • Fax:
Mailing address:
  • Phone: 703-963-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number39262
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: