Healthcare Provider Details

I. General information

NPI: 1760727192
Provider Name (Legal Business Name): MARY HAGEE M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RANDOLPH ST
RADFORD VA
24141-2430
US

IV. Provider business mailing address

147 DEER RUN
WYTHEVILLE VA
24382-9998
US

V. Phone/Fax

Practice location:
  • Phone: 540-633-6533
  • Fax:
Mailing address:
  • Phone: 276-389-9327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 11776
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202005237
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: