Provider Demographics
NPI:1699003392
Name:FAGAN, MICHAEL BRIAN (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:FAGAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 EASTERN PKWY APT 1B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 EASTERN PKWY APT 1B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6037
Practice Address - Country:US
Practice Address - Phone:718-399-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR052154-11041C0700X
NY0521541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty