Healthcare Provider Details

I. General information

NPI: 1780657072
Provider Name (Legal Business Name): GRACE ANN HAGEN MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 LACLEDE
ST LOUIS MO
63108
US

IV. Provider business mailing address

4150 LACLEDE
ST LOUIS MO
63108
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-8148
  • Fax: 314-531-5874
Mailing address:
  • Phone: 314-531-8148
  • Fax: 314-531-5874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2001006557
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: