Provider Demographics
NPI:1912572660
Name:FAGAN, TIFFANY SIMONE (LMHC, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:SIMONE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:SIMONE
Other - Last Name:RAMBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 ESKENAZI AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5187
Mailing Address - Country:US
Mailing Address - Phone:317-880-0000
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003186A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health