MEDICARE: DR. COLLEEN FAGAN PH.D.

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	103TC0700X	Clinical Psychologist	2014016577	MO
2	103TC0700X	Clinical Psychologist	36586	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2014016577	OTHER	MO	LICENSE #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972915379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLLEEN FAGAN PH.D.

Provider Business Mailing Address
First Line	:	2900 NE 60TH ST STE 205
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64119-2091
Country	:	US
Telephone Number	:	816-694-0200
Fax Number	:	888-507-5906

Provider Business Practice Location Address
First Line	:	2900 NE 60TH ST STE 205
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64119-2091
Country	:	US
Telephone Number	:	816-694-0200
Fax Number	:	888-507-5906

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

Provider Enumeration Date	:	05/20/2014
Last Update Date	:	03/20/2026

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