Healthcare Provider Details

I. General information

NPI: 1164084455
Provider Name (Legal Business Name): CAMILLE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WESTLINE INDUSTRIAL DR STE 201
SAINT LOUIS MO
63146-3209
US

IV. Provider business mailing address

27130 HUNT DR
WRIGHT CITY MO
63390-4419
US

V. Phone/Fax

Practice location:
  • Phone: 866-433-9555
  • Fax:
Mailing address:
  • Phone: 314-446-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number2019017425
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: