Healthcare Provider Details

I. General information

NPI: 1528623246
Provider Name (Legal Business Name): MAKAYLA MARIE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2935 BIRCH HOLLOW DR
ANN ARBOR MI
48108-2301
US

IV. Provider business mailing address

4410 W 13 MILE RD
ROYAL OAK MI
48073-6515
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-0990
  • Fax: 734-368-9189
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: