Healthcare Provider Details

I. General information

NPI: 1497717508
Provider Name (Legal Business Name): TED W HAGEN II DMIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/20/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N WILCOX DR STE C
KINGSPORT TN
37660-4986
US

IV. Provider business mailing address

1201 N WILCOX DR STE C
KINGSPORT TN
37660-4986
US

V. Phone/Fax

Practice location:
  • Phone: 423-765-6276
  • Fax:
Mailing address:
  • Phone: 423-765-6276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0000069
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: