MEDICARE: COLLEEN L HAGAN

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	1041C0700X	Clinical Social Worker	001379	GA

General Provider Information

NPI Number	:	1295714442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN L HAGAN

Provider Business Mailing Address
First Line	:	1640 POWERS FERRY RD
Second Line	:	BLDG 29, STE 350
City	:	MARIETTA
State	:	GA
Zip	:	30067-5491
Country	:	US
Telephone Number	:	770-956-9212
Fax Number	:	770-956-9218

Provider Business Practice Location Address
First Line	:	1640 POWERS FERRY RD
Second Line	:	BLDG 29, STE 350
City	:	MARIETTA
State	:	GA
Zip	:	30067-5491
Country	:	US
Telephone Number	:	770-956-9212
Fax Number	:	770-956-9218

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

Provider Enumeration Date	:	01/14/2006
Last Update Date	:	07/08/2007

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Directions to “ COLLEEN L HAGAN ” Practice Location

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