Healthcare Provider Details

I. General information

NPI: 1114910049
Provider Name (Legal Business Name): GAIL HEGEMAN PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GAIL M HEGEMAN PH D

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 03/13/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 COUNTY ROAD B WEST SUITE 144S
ROSEVILLE MN
55113-4100
US

IV. Provider business mailing address

1711 COUNTY ROAD B WEST SUITE 144S
ROSEVILLE MN
55113-4100
US

V. Phone/Fax

Practice location:
  • Phone: 651-635-0909
  • Fax: 612-822-8669
Mailing address:
  • Phone: 651-635-0909
  • Fax: 612-822-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP2464
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: