Healthcare Provider Details

I. General information

NPI: 1760213789
Provider Name (Legal Business Name): SARAH ANN FAGAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N MAIN ST
WHITE RIVER JUNCTION VT
05001-3833
US

IV. Provider business mailing address

PO BOX 70
GEORGES MILLS NH
03751-0070
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-9363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0006582
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: