Provider Demographics
NPI:1417558065
Name:FAGAN, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E 91ST ST APT 4C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1659
Mailing Address - Country:US
Mailing Address - Phone:917-208-3907
Mailing Address - Fax:
Practice Address - Street 1:108 E 91ST ST APT 4C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1659
Practice Address - Country:US
Practice Address - Phone:917-208-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0383881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical