=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043468556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE FAGAN L.P.C., R.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2008
-----------------------------------------------------
Last Update Date | 10/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12125 WOODCREST EXECUTIVE DR SUITE 110
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-275-8599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10820 SUNSET OFFICE DR SUITE 122
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63127-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-954-6553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2004032923
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------