Provider Demographics
NPI:1164506192
Name:FAGAN, TARA (SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FAGAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 MAJESTIC VIEW LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3223
Mailing Address - Country:US
Mailing Address - Phone:904-635-4143
Mailing Address - Fax:
Practice Address - Street 1:1639 MAJESTIC VIEW LN
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-3223
Practice Address - Country:US
Practice Address - Phone:904-635-4143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6601235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887580400Medicaid