Provider Demographics
NPI:1154777803
Name:FAGEN, DOUGLAS BRIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRIAN
Last Name:FAGEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4759 RESERVOIR RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-1921
Mailing Address - Country:US
Mailing Address - Phone:202-944-3071
Mailing Address - Fax:202-454-2292
Practice Address - Street 1:4759 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-1921
Practice Address - Country:US
Practice Address - Phone:202-944-3071
Practice Address - Fax:202-454-2292
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1000067103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical