Provider Demographics
NPI:1083587042
Name:FAGAN, TAMIKA (CBCS, CCHT,NHA)
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:CBCS, CCHT,NHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-4613
Mailing Address - Country:US
Mailing Address - Phone:984-833-7423
Mailing Address - Fax:
Practice Address - Street 1:1225 MANOR DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-4613
Practice Address - Country:US
Practice Address - Phone:984-833-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1138009113251E00000X
NCS4L8A5R7103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No251E00000XAgenciesHome Health