Healthcare Provider Details

I. General information

NPI: 1801490370
Provider Name (Legal Business Name): LETICIA FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 01/07/2021
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 WALNUT PL
ALTAMONTE SPRINGS FL
32701-6458
US

IV. Provider business mailing address

703 WALNUT PL
ALTAMONTE SPRINGS FL
32701-6458
US

V. Phone/Fax

Practice location:
  • Phone: 305-343-3003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: