Healthcare Provider Details

I. General information

NPI: 1144714940
Provider Name (Legal Business Name): ALYSON LYNN FAGAN M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

2931 E BIDDLE ST
BALTIMORE MD
21213-3939
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-1872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number08739
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: