Healthcare Provider Details

I. General information

NPI: 1588806525
Provider Name (Legal Business Name): ALYSSA M FAGAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BERGEN ST
BROOKLYN NY
11201-6302
US

IV. Provider business mailing address

598 19TH ST APT 1
BROOKLYN NY
11218-1044
US

V. Phone/Fax

Practice location:
  • Phone: 718-501-7607
  • Fax:
Mailing address:
  • Phone: 718-501-7607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number010111-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: