Healthcare Provider Details

I. General information

NPI: 1992917421
Provider Name (Legal Business Name): MARC FAGNAN M.A. CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 LONE STAR DRIVE
DALLAS TX
75212
US

IV. Provider business mailing address

3664 PALLOS VERDAS DRIVE
DALLAS TX
75229
US

V. Phone/Fax

Practice location:
  • Phone: 214-467-9787
  • Fax:
Mailing address:
  • Phone: 214-350-3263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number101658
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: