MEDICARE: MR. CLIFFORD RAYMOND FAGAN LCSW CCM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	31107	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	66897	OTHER	TX	CSHCN

General Provider Information

NPI Number	:	1053345553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLIFFORD RAYMOND FAGAN LCSW CCM

Provider Business Mailing Address
First Line	:	800 W AIRPORT FWY
Second Line	:	STE 1100
City	:	IRVING
State	:	TX
Zip	:	75062-6312
Country	:	US
Telephone Number	:	214-704-5879
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 W AIRPORT FWY
Second Line	:	STE 1100
City	:	IRVING
State	:	TX
Zip	:	75062-6312
Country	:	US
Telephone Number	:	214-704-5879
Fax Number	:	888-974-1492

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	02/10/2017

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