Miriam Fagan, PSYD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

31718 Issued in CA

Practice address

111 Smith Ranch Rd
San Rafael, CA 94903-1939

Phone

(415) 491-3003

NPI assigned

Apr 8, 2020

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Nov 8, 2023 through Nov 8, 2027

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1586304000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712016000000",
    "number": "1487283685",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "775 E BLITHEDALE AVE # 141",
            "city": "MILL VALLEY",
            "state": "CA",
            "postal_code": "949411554",
            "telephone_number": "415-569-5113"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 SMITH RANCH RD",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "949031939",
            "telephone_number": "415-491-3003"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FAGAN",
        "first_name": "MIRIAM",
        "name_prefix": "Dr.",
        "credential": "PSYD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-04-08",
        "last_updated": "2024-04-02",
        "certification_date": "2024-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "31718",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ncalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "The Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "99 Montecillo Rd",
            "city": "San Rafael",
            "state": "CA",
            "country_code": "US",
            "postal_code": "949033308",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Exceptional Hearing Services of Northern California, Inc.
• Eyedesigns Optometry
• Chinedu John Ezeji-Okoye, DDS
• Brigitte Faas, DC
• Ashley Malone Fagan
• Molly Fagan, MS
• Evelyn Joan Fahey
• Kim Stafford Fahlen, LMFT
• Jay F. Fairborn, MD
• Tanya Fairclough

• Clinical Psychologist in San Rafael, CA
• Providers in San Rafael, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.