Provider Demographics
NPI:1578953915
Name:FAGAN-NELSON, KATHARINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:FAGAN-NELSON
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 1:1405 HOVEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3324
Mailing Address - Country:US
Mailing Address - Phone:309-826-3566
Mailing Address - Fax:
Practice Address - Street 1:1003 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1429
Practice Address - Country:US
Practice Address - Phone:309-827-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490093161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical