Provider Demographics
NPI:1043468556
Name:FAGAN, SUSAN MARIE (LPC, RN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LPC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10820 SUNSET OFFICE DR
Mailing Address - Street 2:SUITE 122
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1016
Mailing Address - Country:US
Mailing Address - Phone:314-954-6553
Mailing Address - Fax:
Practice Address - Street 1:12125 WOODCREST EXECUTIVE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5001
Practice Address - Country:US
Practice Address - Phone:314-275-8599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004032923101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health