Healthcare Provider Details

I. General information

NPI: 1093635633
Provider Name (Legal Business Name): BREANNA MARIE HAGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 VIKING DR STE 180
EDEN PRAIRIE MN
55344-7222
US

IV. Provider business mailing address

2110 TURPIN ST
SAINT PETER MN
56082-1776
US

V. Phone/Fax

Practice location:
  • Phone: 612-712-4307
  • Fax: 600-513-7773
Mailing address:
  • Phone: 612-712-4307
  • Fax: 800-513-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: