Provider Demographics
NPI:1619456910
Name:FAGEN, RENEE ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ANN
Last Name:FAGEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:CLEGHORN
Mailing Address - State:IA
Mailing Address - Zip Code:51014-7724
Mailing Address - Country:US
Mailing Address - Phone:515-418-7717
Mailing Address - Fax:
Practice Address - Street 1:1551 INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1859
Practice Address - Country:US
Practice Address - Phone:712-258-4700
Practice Address - Fax:712-258-4777
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088631103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical