Provider Demographics
NPI:1831514371
Name:FAGAN, ANTHONYESHA
Entity type:Individual
Prefix:
First Name:ANTHONYESHA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 SOUTHBRIAR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-2561
Mailing Address - Country:US
Mailing Address - Phone:419-705-9168
Mailing Address - Fax:
Practice Address - Street 1:821 SOUTHBRIAR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-2561
Practice Address - Country:US
Practice Address - Phone:419-279-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YA0400X, 101YM0800X
OH4807696171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171W00000XOther Service ProvidersContractor