Provider Demographics
NPI:1821799487
Name:FAGAN, MARIA ANNUNZIATA (MED, LAC, NCC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ANNUNZIATA
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MED, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 WYCKOFF AVE STE AND303
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-3186
Mailing Address - Country:US
Mailing Address - Phone:551-319-2029
Mailing Address - Fax:
Practice Address - Street 1:666 GODWIN AVE STE AND330
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1449
Practice Address - Country:US
Practice Address - Phone:551-319-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00710200106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist