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NPI Code Detail

MEDICARE: MARY L HAGSTROM CDP

MEDICARE: MARY L HAGSTROM CDP
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
1101YA0400XAddiction (Substance Use Disorder) CounselorCP00001268WA

General Provider Information

NPI Number : 1538238191
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY L HAGSTROM CDP
Provider Business Mailing Address
First Line : 613 W MAIN AVE
Second Line :
City : CHEWELAH
State : WA
Zip : 99109-9146
Country : US
Telephone Number : 509-935-0866
Fax Number :
Provider Business Practice Location Address
First Line : 165 E HAWTHORNE AVE
Second Line :
City : COLVILLE
State : WA
Zip : 99114-2629
Country : US
Telephone Number : 509-684-4597
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/07/2006
Last Update Date : 07/08/2007

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