Provider Demographics
NPI:1316050164
Name:FAGEN, STANLEY A (PHD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:A
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 1:6123 MONTROSE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:601-881-3700
Mailing Address - Fax:301-468-1862
Practice Address - Street 1:6123 MONTROSE RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852
Practice Address - Country:US
Practice Address - Phone:601-881-3700
Practice Address - Fax:301-468-1862
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD372103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD236598OtherKAISER
MD206604OtherMHN
MD485491000OtherMAGALLAN
MD63558001OtherBCBS OF MD
MD7554447OtherAETNA
DCA2840074OtherBCBS OF DC
MD530196598OtherTRICARE
MD699555100Medicaid
MD699555100Medicaid