Provider Demographics
NPI:1730404567
Name:FAGIN, SUSAN MARY (MENTAL HEALTH COUNSE)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:FAGIN
Suffix:
Gender:F
Credentials:MENTAL HEALTH COUNSE
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARY
Other - Last Name:FAGIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:161 HIGH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3660
Mailing Address - Country:US
Mailing Address - Phone:503-371-7655
Mailing Address - Fax:
Practice Address - Street 1:565 UNION ST NE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2416
Practice Address - Country:US
Practice Address - Phone:971-719-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 106S00000X, 101YM0800X
OR9215171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01YM0800X-Medicaid
OR0LYM0800XMedicaid