Provider Demographics
NPI:1235210543
Name:FAGAN, MELISSA L (LMHC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 LOUISIANA BLVD NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1448
Mailing Address - Country:US
Mailing Address - Phone:505-888-1686
Mailing Address - Fax:505-888-1683
Practice Address - Street 1:3901 LOUISIANA BLVD NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1448
Practice Address - Country:US
Practice Address - Phone:505-888-1686
Practice Address - Fax:505-888-1683
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0184771101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64079775Medicaid