Healthcare Provider Details

I. General information

NPI: 1154049252
Provider Name (Legal Business Name): MADISON ELIZABETH FAGAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/23/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S WADSWORTH BLVD STE 102
LAKEWOOD CO
80227-3246
US

IV. Provider business mailing address

1250 CHEROKEE ST APT 1620
DENVER CO
80204-3762
US

V. Phone/Fax

Practice location:
  • Phone: 720-962-4555
  • Fax:
Mailing address:
  • Phone: 630-780-0073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT.0007541
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: