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NPI Code Detail

MEDICARE: ALYSSA L FAGAN-CLARK LCSW

MEDICARE: ALYSSA L FAGAN-CLARK LCSW
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
11041C0700XClinical Social WorkerLCSW-21945AZ

General Provider Information

NPI Number : 1154754943
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALYSSA L FAGAN-CLARK LCSW
Provider Business Mailing Address
First Line : 7500 N DREAMY DRAW DR STE 145
Second Line :
City : PHOENIX
State : AZ
Zip : 85020-4668
Country : US
Telephone Number : 480-886-2454
Fax Number : 602-409-0499
Provider Business Practice Location Address
First Line : 20440 N 27TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85027-3240
Country : US
Telephone Number : 480-882-4545
Fax Number : 602-910-2949
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/15/2013
Last Update Date : 12/27/2023

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Directions to “ ALYSSA L FAGAN-CLARK LCSW” Practice Location

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