Provider Demographics
NPI:1144636234
Name:FAGAN, MITCHELL ERNEST (MA SLP-CCC)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ERNEST
Last Name:FAGAN
Suffix:
Gender:M
Credentials:MA SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-1309
Mailing Address - Country:US
Mailing Address - Phone:718-218-2444
Mailing Address - Fax:
Practice Address - Street 1:820 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-1309
Practice Address - Country:US
Practice Address - Phone:718-218-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist