Provider Demographics
NPI:1679879795
Name:KAGAN, BARRY JACOB (LMT)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:JACOB
Last Name:KAGAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 MANORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3164
Mailing Address - Country:US
Mailing Address - Phone:301-332-8261
Mailing Address - Fax:
Practice Address - Street 1:3316 MANORWOOD DR
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-3164
Practice Address - Country:US
Practice Address - Phone:301-332-8261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM03504225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist