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General NPI Number Information
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NPI Number | 1063962900
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Entity Type | Organization
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Legal Business Name | TERESE FAGAN LCSW LLC
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Dates
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Enumeration Date | 10/04/2016
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Last Update Date | 10/04/2016
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Provider Practice Location Address
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Address Line | 45 S MAIN ST SUITE 107
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City | WEST HARTFORD
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State | CT
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Zip | 06107-2441
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Country | US
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Telephone | 860-778-3304
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Fax |
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Provider Business Mailing Address
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Address Line | 1131 TOLLAND TPKE UNIT 258
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City | MANCHESTER
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State | CT
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Zip | 06042-1679
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | TERESE BALLET
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Credential |
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Telephone | 860-778-3304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 008738
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License Number State | CT
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