Healthcare Provider Details

I. General information

NPI: 1811621220
Provider Name (Legal Business Name): KETIA MAGENE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 OAKWOOD BLVD STE 130
HOLLYWOOD FL
33020-1937
US

IV. Provider business mailing address

1 OAKWOOD BLVD
HOLLYWOOD FL
33020-1956
US

V. Phone/Fax

Practice location:
  • Phone: 954-925-3844
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI5524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: