Provider Demographics
NPI:1922270537
Name:FAGAN, ELIZABETH ANNE (SLPD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:SLPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3303
Mailing Address - Country:US
Mailing Address - Phone:207-797-2351
Mailing Address - Fax:207-797-8650
Practice Address - Street 1:985 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3303
Practice Address - Country:US
Practice Address - Phone:207-797-2351
Practice Address - Fax:207-797-8650
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist