Healthcare Provider Details

I. General information

NPI: 1922270537
Provider Name (Legal Business Name): ELIZABETH ANNE FAGAN SLPD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 FOREST AVE
PORTLAND ME
04103-3303
US

IV. Provider business mailing address

985 FOREST AVE
PORTLAND ME
04103-3303
US

V. Phone/Fax

Practice location:
  • Phone: 207-797-2351
  • Fax: 207-797-8650
Mailing address:
  • Phone: 207-797-2351
  • Fax: 207-797-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP886
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: