Provider Demographics
NPI:1134542442
Name:DEAGAN, CRISTIN GLORIA
Entity type:Individual
Prefix:
First Name:CRISTIN
Middle Name:GLORIA
Last Name:DEAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 CAREY ST
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-1945
Mailing Address - Country:US
Mailing Address - Phone:945-661-3669
Mailing Address - Fax:
Practice Address - Street 1:160 CAREY ST
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-1945
Practice Address - Country:US
Practice Address - Phone:845-661-3669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
NY024453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency