Provider Demographics
NPI:1720859465
Name:FAGRE, EMILY (LCSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FAGRE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3172 CANTRELL LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1909
Mailing Address - Country:US
Mailing Address - Phone:630-908-0051
Mailing Address - Fax:
Practice Address - Street 1:3172 CANTRELL LN
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1909
Practice Address - Country:US
Practice Address - Phone:630-908-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040127681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical