Provider Demographics
NPI:1073572681
Name:FAGIN, C GAVRIEL (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:C
Middle Name:GAVRIEL
Last Name:FAGIN
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2627
Mailing Address - Country:US
Mailing Address - Phone:917-257-8626
Mailing Address - Fax:
Practice Address - Street 1:420 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1000
Practice Address - Country:US
Practice Address - Phone:917-257-8626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078842-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical