Provider Demographics
NPI:1790154763
Name:FAGAN, SARA KATE
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:KATE
Last Name: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 1:60 S FULLERTON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2663
Mailing Address - Country:US
Mailing Address - Phone:973-744-6522
Mailing Address - Fax:
Practice Address - Street 1:60 S FULLERTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2663
Practice Address - Country:US
Practice Address - Phone:973-744-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05819200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker