Healthcare Provider Details

I. General information

NPI: 1336351204
Provider Name (Legal Business Name): BRENDA ANN FAGAN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 SILVER AVE
SAN FRANCISCO CA
94112-1510
US

IV. Provider business mailing address

1312 JOSEPHINE ST APT 5
BERKELEY CA
94703-1140
US

V. Phone/Fax

Practice location:
  • Phone: 415-469-2239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT6824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: