Healthcare Provider Details

I. General information

NPI: 1912330747
Provider Name (Legal Business Name): CARRIE FAGAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE GOODBERLET PT

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CLIFTON SPRINGS PROFESSIONAL PARK
CLIFTON SPRINGS NY
14432-1041
US

IV. Provider business mailing address

210 CLIFTON SPRINGS PROFESSIONAL PARK
CLIFTON SPRINGS NY
14432-1041
US

V. Phone/Fax

Practice location:
  • Phone: 315-462-3588
  • Fax: 315-462-6590
Mailing address:
  • Phone: 315-906-0051
  • Fax: 315-906-0058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number036489
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: