Provider Demographics
NPI:1053345553
Name:FAGAN, CLIFFORD RAYMOND (LCSW CCM)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:RAYMOND
Last Name:FAGAN
Suffix:
Gender:M
Credentials:LCSW CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W AIRPORT FWY
Mailing Address - Street 2:STE 1100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-6312
Mailing Address - Country:US
Mailing Address - Phone:214-704-5879
Mailing Address - Fax:
Practice Address - Street 1:800 W AIRPORT FWY
Practice Address - Street 2:STE 1100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-6312
Practice Address - Country:US
Practice Address - Phone:214-704-5879
Practice Address - Fax:888-974-1492
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1565863-02Medicaid
TX66897OtherCSHCN
TX66897OtherCSHCN