Provider Demographics
NPI:1629228101
Name:FAGAN, SHANE SIBLEY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANE
Middle Name:SIBLEY
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 1:2316 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-3222
Mailing Address - Country:US
Mailing Address - Phone:703-864-6794
Mailing Address - Fax:
Practice Address - Street 1:919 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3648
Practice Address - Country:US
Practice Address - Phone:703-864-6794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904005331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health