Provider Demographics
NPI:1396235388
Name:FRAGNOLI, LOUISE
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:FRAGNOLI
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 1:47905 FREEDOM VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2597
Mailing Address - Country:US
Mailing Address - Phone:586-779-7000
Mailing Address - Fax:
Practice Address - Street 1:26001 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2309
Practice Address - Country:US
Practice Address - Phone:586-779-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005385224ZF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201005385Medicaid