Healthcare Provider Details

I. General information

NPI: 1659516623
Provider Name (Legal Business Name): KELLY ANN FAGAN CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352 COUNTY ROUTE 41
GREENVILLE NY
12083-4626
US

IV. Provider business mailing address

2352 COUNTY ROUTE 41
GREENVILLE NY
12083-4626
US

V. Phone/Fax

Practice location:
  • Phone: 518-966-5447
  • Fax: 518-966-5447
Mailing address:
  • Phone: 518-966-5447
  • Fax: 518-966-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number008897
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: