Provider Demographics
NPI:1902361116
Name:FAGAN, PAUL (MA, LPC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:RIVER
Other - Middle Name:
Other - Last Name:FAGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:1235 SE DIVISION ST STE 201B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1099
Mailing Address - Country:US
Mailing Address - Phone:503-917-4768
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST STE 201B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1099
Practice Address - Country:US
Practice Address - Phone:503-917-4768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR4848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health