Basic Information
| Provider Information | |||||||||
| NPI: | 1023254950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUMMINGS FAGAN | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAGAN | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14527 7TH ST | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335233102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525211474 | ||||||||
| FaxNumber: | 3525211477 | ||||||||
| Practice Location | |||||||||
| Address1: | 14527 7TH ST | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335233102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525211474 | ||||||||
| FaxNumber: | 3525211477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2008 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | FL | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | MH 9645 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 104546900 | 05 | FL | MEDICAID | 000649000 | 05 | FL | MEDICAID |