Healthcare Provider Details

I. General information

NPI: 1295471340
Provider Name (Legal Business Name): STEPHANIE JAVIER FAGBEMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6106
US

IV. Provider business mailing address

933 NEWGATE RD
WEST SUFFIELD CT
06093-3012
US

V. Phone/Fax

Practice location:
  • Phone: 617-983-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1021147
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: