Healthcare Provider Details

I. General information

NPI: 1245795939
Provider Name (Legal Business Name): IAN K. HAGEMANN MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MARTIN LUTHER KING JR WAY S
SEATTLE WA
98144-4801
US

IV. Provider business mailing address

1136 13TH AVE APT 108
SEATTLE WA
98122-4405
US

V. Phone/Fax

Practice location:
  • Phone: 206-322-7676
  • Fax:
Mailing address:
  • Phone: 206-445-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSA60977729
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: