Healthcare Provider Details

I. General information

NPI: 1376342741
Provider Name (Legal Business Name): KATHRYN GREER FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 GRANDVIEW AVE
VALPARAISO FL
32580-1542
US

IV. Provider business mailing address

170 GRANDVIEW AVE
VALPARAISO FL
32580-1542
US

V. Phone/Fax

Practice location:
  • Phone: 334-224-2630
  • Fax:
Mailing address:
  • Phone: 334-224-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA23327
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: