MEDICARE: KRISTINE LYNN HAGEN MS, CCC-SLP/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146.005085	IL

General Provider Information

NPI Number	:	1023533528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE LYNN HAGEN MS, CCC-SLP/L

Provider Business Mailing Address
First Line	:	501 E LORENA AVE
Second Line	:
City	:	WOOD RIVER
State	:	IL
Zip	:	62095-2123
Country	:	US
Telephone Number	:	618-254-0607
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 E LORENA AVE
Second Line	:
City	:	WOOD RIVER
State	:	IL
Zip	:	62095-2123
Country	:	US
Telephone Number	:	618-254-0607
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2017
Last Update Date	:	03/17/2018

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