Healthcare Provider Details

I. General information

NPI: 1700177193
Provider Name (Legal Business Name): SUELLEN FAGIN-ALLEN L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 N SEMORAN BLVD SUITE 201
ORLANDO FL
32807-3555
US

IV. Provider business mailing address

1417 N SEMORAN BLVD SUITE 201
ORLANDO FL
32807-3555
US

V. Phone/Fax

Practice location:
  • Phone: 407-242-2956
  • Fax: 407-282-0552
Mailing address:
  • Phone: 407-242-2956
  • Fax: 407-282-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9111
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: