Healthcare Provider Details

I. General information

NPI: 1467278838
Provider Name (Legal Business Name): JUSTIN LYNDSEY HAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8822 SHADY LEAF
SAN ANTONIO TX
78254-5516
US

IV. Provider business mailing address

8822 SHADY LEAF
SAN ANTONIO TX
78254-5516
US

V. Phone/Fax

Practice location:
  • Phone: 270-702-0856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: