Healthcare Provider Details

I. General information

NPI: 1922078351
Provider Name (Legal Business Name): SUSAN FAGAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EMILY WAY
WEST HARTFORD CT
06107-3136
US

IV. Provider business mailing address

1 EMILY WAY
WEST HARTFORD CT
06107-3136
US

V. Phone/Fax

Practice location:
  • Phone: 860-561-7022
  • Fax:
Mailing address:
  • Phone: 860-561-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005279
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: