Healthcare Provider Details

I. General information

NPI: 1164506192
Provider Name (Legal Business Name): TARA FAGAN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 MAJESTIC VIEW LN
ORANGE PARK FL
32003-3223
US

IV. Provider business mailing address

1639 MAJESTIC VIEW LN
ORANGE PARK FL
32003-3223
US

V. Phone/Fax

Practice location:
  • Phone: 904-635-4143
  • Fax:
Mailing address:
  • Phone: 904-635-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA6601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: