Healthcare Provider Details

I. General information

NPI: 1851417927
Provider Name (Legal Business Name): COREY N FAGAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUTHRIE ANX UW BOX 351635
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

1 GUTHRIE ANX UW BOX 351635
SEATTLE WA
98195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-6511
  • Fax: 206-616-8367
Mailing address:
  • Phone: 206-543-6511
  • Fax: 206-616-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00001365
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: