Provider Demographics
NPI:1114606639
Name:FAGAN, CASEY (CSW)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S 500 W STE 150
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2297
Mailing Address - Country:US
Mailing Address - Phone:801-359-2256
Mailing Address - Fax:
Practice Address - Street 1:525 S 500 W STE 150
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2297
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13408629-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker