Provider Demographics
NPI:1730159146
Name:FANGER, MARK G (EDD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:FANGER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 ROUNDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1218
Mailing Address - Country:US
Mailing Address - Phone:617-969-4040
Mailing Address - Fax:617-795-2065
Practice Address - Street 1:73 ROUNDWOOD RD
Practice Address - Street 2:
Practice Address - City:NEWTON UPPER FALLS
Practice Address - State:MA
Practice Address - Zip Code:02464-1218
Practice Address - Country:US
Practice Address - Phone:617-969-4040
Practice Address - Fax:617-795-2065
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2215103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103T00000X, 103TP2701X, 106H00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist