Healthcare Provider Details

I. General information

NPI: 1629074869
Provider Name (Legal Business Name): SUSAN GAIL HAGEMAN D.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN GAIL ANDERSON

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 S LOCUST ST
GRAND ISLAND NE
68801-6751
US

IV. Provider business mailing address

929 S LOCUST ST
GRAND ISLAND NE
68801-6751
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-9700
  • Fax: 308-382-9898
Mailing address:
  • Phone: 308-382-9700
  • Fax: 308-382-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2201
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2201
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: