Provider Demographics
NPI:1427527407
Name:FAGAN, CHARNA (MA COUNSELING)
Entity type:Individual
Prefix:
First Name:CHARNA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MA COUNSELING
Other - Prefix:
Other - First Name:CHARNA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA COUNSELING
Mailing Address - Street 1:PO BOX 12104
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-2104
Mailing Address - Country:US
Mailing Address - Phone:863-608-6427
Mailing Address - Fax:
Practice Address - Street 1:2400 S RIDGEWOOD AVE STE 32
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3073
Practice Address - Country:US
Practice Address - Phone:863-608-6427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor