Provider Demographics
NPI:1588806525
Name:FAGAN, ALYSSA M (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:M
Last Name:FAGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 19TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1044
Mailing Address - Country:US
Mailing Address - Phone:718-501-7607
Mailing Address - Fax:
Practice Address - Street 1:20 BERGEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6302
Practice Address - Country:US
Practice Address - Phone:718-501-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010111-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics