Provider Demographics
NPI:1396891719
Name:FAGAN, KEVIN CHARLES (LICSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:CHARLES
Last Name:FAGAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 JEFFERSON BLVD.
Mailing Address - Street 2:SUITE 2009
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:401-921-5400
Mailing Address - Fax:401-921-5402
Practice Address - Street 1:931 JEFFERSON BLVD.
Practice Address - Street 2:SUITE 2009
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-921-5400
Practice Address - Fax:401-921-5402
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW016201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical