Provider Demographics
NPI:1508967845
Name:FAGAN, TAMRA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:ANN
Last Name:FAGAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TAMRA
Other - Middle Name:ANN
Other - Last Name:OGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10414
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-0414
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:211 COOL SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-7242
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001827103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4057799OtherBCBS
TN3982871Medicaid
TN3982871Medicaid