MEDICARE: MRS. MELISSA HAGEN LMSW

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	6801087837	MI

General Provider Information

NPI Number	:	1710309786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA HAGEN LMSW

Provider Business Mailing Address
First Line	:	27145 S FIRST POINT LANDING RD
Second Line	:
City	:	GOETZVILLE
State	:	MI
Zip	:	49736-9371
Country	:	US
Telephone Number	:	906-440-7105
Fax Number	:

Provider Business Practice Location Address
First Line	:	27145 S FIRST POINT LANDING RD
Second Line	:
City	:	GOETZVILLE
State	:	MI
Zip	:	49736-9371
Country	:	US
Telephone Number	:	906-440-7105
Fax Number	:

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

Provider Enumeration Date	:	01/10/2014
Last Update Date	:	10/28/2022

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