Provider Demographics
NPI:1285742627
Name:FAGAN, LAURIE LEE (LBSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:LEE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 CRANBERRY DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:MI
Mailing Address - Zip Code:48049-4403
Mailing Address - Country:US
Mailing Address - Phone:810-984-2491
Mailing Address - Fax:810-987-9105
Practice Address - Street 1:2601 13TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6546
Practice Address - Country:US
Practice Address - Phone:810-987-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802012074104100000X
MI1-01753101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)