Basic Information
| Provider Information | |||||||||
| NPI: | 1285742627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAGAN | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3405 CRANBERRY DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480494403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109842491 | ||||||||
| FaxNumber: | 8109879105 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 13TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109879100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802012074 | MI | X | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 1-01753 | MI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.