Healthcare Provider Details

I. General information

NPI: 1629228101
Provider Name (Legal Business Name): SHANE SIBLEY FAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 DUKE ST
ALEXANDRIA VA
22314-3648
US

IV. Provider business mailing address

2316 VALLEY DR
ALEXANDRIA VA
22302-3222
US

V. Phone/Fax

Practice location:
  • Phone: 703-864-6794
  • Fax:
Mailing address:
  • Phone: 703-864-6794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904005331
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: