1053345553 NPI number — MR. CLIFFORD RAYMOND FAGAN LCSW CCM

Table of content: MR. CLIFFORD RAYMOND FAGAN LCSW CCM (NPI 1053345553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053345553 NPI number — MR. CLIFFORD RAYMOND FAGAN LCSW CCM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAGAN
Provider First Name:
CLIFFORD
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW CCM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053345553
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 W AIRPORT FWY
Provider Second Line Business Mailing Address:
STE 1100
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75062-6312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-704-5879
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 W AIRPORT FWY
Provider Second Line Business Practice Location Address:
STE 1100
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75062-6312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-704-5879
Provider Business Practice Location Address Fax Number:
888-974-1492
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  31107 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1565863-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 66897 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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