Healthcare Provider Details

I. General information

NPI: 1235518580
Provider Name (Legal Business Name): JAMES HAGLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N BRINTON AVE
DIXON IL
61021-9532
US

IV. Provider business mailing address

2209 18TH AVE
ROCKFORD IL
61104-5535
US

V. Phone/Fax

Practice location:
  • Phone: 815-288-5561
  • Fax:
Mailing address:
  • Phone: 815-713-6863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: