Provider Demographics
NPI:1699263616
Name:FAGEN, MOLLY (PT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FAGEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16686 NW 194TH TER
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-8182
Mailing Address - Country:US
Mailing Address - Phone:352-382-7214
Mailing Address - Fax:
Practice Address - Street 1:4842 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-3813
Practice Address - Country:US
Practice Address - Phone:352-376-8821
Practice Address - Fax:352-382-7781
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist