Healthcare Provider Details

I. General information

NPI: 1710204268
Provider Name (Legal Business Name): MARGARET LOUSIE FAGAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RACHEL LN
IVORYTON CT
06442-1154
US

IV. Provider business mailing address

20 RACHEL LN
IVORYTON CT
06442-1154
US

V. Phone/Fax

Practice location:
  • Phone: 860-391-2070
  • Fax:
Mailing address:
  • Phone: 860-391-2070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number004676
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: