Healthcare Provider Details

I. General information

NPI: 1508192261
Provider Name (Legal Business Name): ERIN M HAGEDORN MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SALISBURY ST
WORCESTER MA
01609-1265
US

IV. Provider business mailing address

20 EDGEWOOD ST APT 3
WORCESTER MA
01602-3333
US

V. Phone/Fax

Practice location:
  • Phone: 508-767-7421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 765
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2261
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: