Provider Demographics
NPI:1235262619
Name:FAGAN-DYER, KELLY ANNE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:FAGAN-DYER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 SARA DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-2828
Mailing Address - Country:US
Mailing Address - Phone:724-223-7803
Mailing Address - Fax:724-223-7804
Practice Address - Street 1:190 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4349
Practice Address - Country:US
Practice Address - Phone:724-223-7803
Practice Address - Fax:724-223-7804
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW125236171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator