MEDICARE: HOLLY H HAGSTROM LPC

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	101YM0800X	Mental Health Counselor	3556-125	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083805246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY H HAGSTROM LPC

Provider Business Mailing Address
First Line	:	61051 E SUMMIT RD
Second Line	:
City	:	ASHLAND
State	:	WI
Zip	:	54806-4402
Country	:	US
Telephone Number	:	715-682-6266
Fax Number	:	715-682-3526

Provider Business Practice Location Address
First Line	:	405 LAKE SHORE DR E
Second Line	:
City	:	ASHLAND
State	:	WI
Zip	:	54806-1837
Country	:	US
Telephone Number	:	715-682-3523
Fax Number	:	715-682-3526

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

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/05/2007

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Directions to “ HOLLY H HAGSTROM LPC” Practice Location

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