MEDICARE: DREVIS L HAGER ED D LP

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	103TC0700X	Clinical Psychologist	LP2999	MN

General Provider Information

NPI Number	:	1902988017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DREVIS L HAGER ED D LP

Provider Business Mailing Address
First Line	:	2497 7TH AVE E
Second Line	:	SUITE 101
City	:	NORTH ST PAUL
State	:	MN
Zip	:	55109-2496
Country	:	US
Telephone Number	:	651-769-6437
Fax Number	:	651-769-6426

Provider Business Practice Location Address
First Line	:	8085 WAYZATA BLVD
Second Line	:	SUITE 101
City	:	NORTH ST PAUL
State	:	MN
Zip	:	55426-1456
Country	:	US
Telephone Number	:	651-769-6300
Fax Number	:	651-769-6349

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	07/08/2007

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