Provider Demographics
NPI:1629157615
Name:FAGAN, ALICIA MARY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:MARY
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 NORTH MAIN STREET
Mailing Address - Street 2:STE 2C
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489
Mailing Address - Country:US
Mailing Address - Phone:860-621-2280
Mailing Address - Fax:860-628-0219
Practice Address - Street 1:51 NORTH MAIN STREET
Practice Address - Street 2:STE 2C
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-621-2280
Practice Address - Fax:860-628-0219
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000422101YA0400X
CT0006181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004149531Medicaid
CT004149531Medicaid