=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619683448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXA FAGAN PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2023
-----------------------------------------------------
Last Update Date | 01/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24546 KINGSLAND BLVD
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-913-8747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1699 HERMANN DR UNIT 5134
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77004-8137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-963-0694
-----------------------------------------------------
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 | 39262
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------