MEDICARE: JUSTICE IVY HAGG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		TN

General Provider Information

NPI Number	:	1740980655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTICE IVY HAGG

Provider Business Mailing Address
First Line	:	1070 WILSON RDG
Second Line	:
City	:	LAKE CORMORANT
State	:	MS
Zip	:	38641-9486
Country	:	US
Telephone Number	:	901-463-8873
Fax Number	:

Provider Business Practice Location Address
First Line	:	1070 WILSON RDG
Second Line	:
City	:	LAKE CORMORANT
State	:	MS
Zip	:	38641-9486
Country	:	US
Telephone Number	:	901-463-8873
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2023
Last Update Date	:	03/08/2023

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Directions to “ JUSTICE IVY HAGG ” Practice Location

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