Provider Demographics
NPI:1679839997
Name:FAGAN, STEPHANIE A (LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 WISCONSIN AVE NW
Mailing Address - Street 2:APT. 501
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016
Mailing Address - Country:US
Mailing Address - Phone:347-254-4668
Mailing Address - Fax:
Practice Address - Street 1:1006 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2170
Practice Address - Country:US
Practice Address - Phone:860-774-2020
Practice Address - Fax:860-779-5437
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500813571041C0700X
CT12371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid