Provider Demographics
NPI:1992425516
Name:FAGELL, PHYLLIS LAURA (LCPC)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LAURA
Last Name:FAGELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 THOREAU DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-3162
Mailing Address - Country:US
Mailing Address - Phone:301-213-3997
Mailing Address - Fax:
Practice Address - Street 1:5272 RIVER RD STE 510
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-1457
Practice Address - Country:US
Practice Address - Phone:301-213-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty