Active NPI
Willaim Thomas Fagan, LPC
- Professional Counselor
- Bend, OR
National Provider Identifier
1588905319
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- C4302
- Practice address
- 1569 SW Nancy Way
Bend, OR 97702-3234 - Phone
- (541) 617-0377
- Fax
- (541) 617-0377
- NPI assigned
- Mar 4, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | R2719 | OR | |
| Professional Counselor | 101YP2500X | C4302 | OR | Primary |
Addresses
Primary practice location
1569 SW Nancy Way
Bend, OR 97702-3234
Mailing address
3616 SW Reindeer Ave
Redmond, OR 97756-7953
Phone (541) 508-9593
Other practice location 1
676 NE Negus Way
Redmond, OR 97756-8527
Phone (541) 516-4087
Other practice location 2
339 SW Century Dr Ste 201
Bend, OR 97702-1338
Phone (541) 508-9593
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Oct 31, 2024 through Oct 31, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R2719 | OR | MD | Addiction (Substance Use Disorder) Counselor |
| C4302 | OR | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1362355200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1565827200000",
"number": "1588905319",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3616 SW REINDEER AVE",
"city": "REDMOND",
"state": "OR",
"postal_code": "977567953",
"telephone_number": "541-508-9593"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1569 SW NANCY WAY",
"city": "BEND",
"state": "OR",
"postal_code": "977023234",
"telephone_number": "541-617-0377",
"fax_number": "541-617-0377"
}
],
"practiceLocations": [
{
"address_1": "676 NE Negus Way",
"address_purpose": "LOCATION",
"city": "Redmond",
"state": "OR",
"postal_code": "977568527",
"country_code": "US",
"telephone_number": "541-516-4087",
"fax_number": "541-504-1195",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "339 SW Century Dr Ste 201",
"address_purpose": "LOCATION",
"city": "Bend",
"state": "OR",
"postal_code": "977021338",
"country_code": "US",
"telephone_number": "541-508-9593",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "FAGAN",
"first_name": "WILLAIM",
"middle_name": "THOMAS",
"credential": "LPC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-03-04",
"last_updated": "2019-08-15",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "OR",
"license": "R2719",
"primary": false
},
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "OR",
"license": "C4302",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bend, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2019; 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.