Healthcare Provider Details

I. General information

NPI: 1790236370
Provider Name (Legal Business Name): AMBER FAGERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30000 HIVELEY ST
INKSTER MI
48141-1089
US

IV. Provider business mailing address

716 DAVENPORT DR
DUNDEE MI
48131-9402
US

V. Phone/Fax

Practice location:
  • Phone: 734-728-3400
  • Fax:
Mailing address:
  • Phone: 734-634-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: