Provider Demographics
NPI:1194002873
Name:FAGAN, RONALD WALTER
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:WALTER
Last Name:FAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 RIDGEWAY CT
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-5266
Mailing Address - Country:US
Mailing Address - Phone:818-665-9555
Mailing Address - Fax:888-656-4789
Practice Address - Street 1:5508 RIDGEWAY CT
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-5266
Practice Address - Country:US
Practice Address - Phone:818-665-9555
Practice Address - Fax:888-656-4789
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39067106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist