Healthcare Provider Details

I. General information

NPI: 1518340637
Provider Name (Legal Business Name): ELIZABETH MARIE HAGERMOSER LP,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7633 GANSER WAY STE 204
MADISON WI
53719-2092
US

IV. Provider business mailing address

7633 GANSER WAY STE 204
MADISON WI
53719-2092
US

V. Phone/Fax

Practice location:
  • Phone: 608-829-1800
  • Fax: 608-829-1885
Mailing address:
  • Phone: 608-829-1800
  • Fax: 608-829-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10565
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3506-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: