=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487283685
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRIAM FAGAN PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2020
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 SMITH RANCH RD
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94903-1939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-491-3003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 775 E BLITHEDALE AVE # 141
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-1554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-569-5113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 31718
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------