Healthcare Provider Details

I. General information

NPI: 1679649446
Provider Name (Legal Business Name): KERI BETH FAGG SPEECH LANGUAGE PATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5214 S EAST STREET BUILDING D SUITE 1
INDIANAPOLIS IN
46227
US

IV. Provider business mailing address

5214 S EAST STREET BUILDING D SUITE 1
INDIANAPOLIS IN
46227
US

V. Phone/Fax

Practice location:
  • Phone: 800-486-4449
  • Fax: 317-780-3750
Mailing address:
  • Phone: 800-486-4449
  • Fax: 317-780-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22003584A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: