Provider Demographics
NPI:1023771540
Name:FAGAN, TRICIA HOPE (LMHC)
Entity type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:HOPE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 JENNINGS TRCE
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:FL
Mailing Address - Zip Code:32564-9660
Mailing Address - Country:US
Mailing Address - Phone:850-375-4375
Mailing Address - Fax:
Practice Address - Street 1:1200 E JAMES LEE BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3126
Practice Address - Country:US
Practice Address - Phone:506-894-6878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17703101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor