Provider Demographics
NPI:1700011020
Name:BROWN-FAGAN, LISA EVETTE
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:EVETTE
Last Name:BROWN-FAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S SAGINAW ST
Mailing Address - Street 2:302
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1841
Mailing Address - Country:US
Mailing Address - Phone:810-814-3535
Mailing Address - Fax:
Practice Address - Street 1:901 CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-1552
Practice Address - Country:US
Practice Address - Phone:810-232-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-17
Last Update Date:2009-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011313101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional