Provider Demographics
NPI:1184183642
Name:FAGAN, COURTNEY LYNNE (MS CCC-SLP, QOM)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNNE
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MS CCC-SLP, QOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N MCMULLEN BOOTH RD STE D4
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2129
Mailing Address - Country:US
Mailing Address - Phone:727-458-3902
Mailing Address - Fax:
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD STE D4
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2129
Practice Address - Country:US
Practice Address - Phone:727-458-3902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist