Provider Demographics
NPI:1881124964
Name:FAGAN, RICK K (LCPC)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:K
Last Name:FAGAN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 WALL ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1959
Mailing Address - Country:US
Mailing Address - Phone:618-367-2194
Mailing Address - Fax:
Practice Address - Street 1:785 WALL ST STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:618-367-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional