=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770416604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUP TO NUTS SPEECH AND FEEDING THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2026
-----------------------------------------------------
Last Update Date | 06/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 MASSAPEQUA AVE
-----------------------------------------------------
City | MASSAPEQUA PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11762-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-306-4707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 MASSAPEQUA AVE
-----------------------------------------------------
City | MASSAPEQUA PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11762-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-306-4707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SLP/OWNER
-----------------------------------------------------
Name | KRISTEN FAGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-306-4707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------