Healthcare Provider Details

I. General information

NPI: 1649761768
Provider Name (Legal Business Name): DEBRA ANN FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 N ELK ST
SANDUSKY MI
48471-1129
US

IV. Provider business mailing address

137 N ELK ST
SANDUSKY MI
48471-1129
US

V. Phone/Fax

Practice location:
  • Phone: 810-648-3017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number520100500
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: