Provider Demographics
NPI:1043374200
Name:HAGEN, SUSAN JANE (LCPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:HAGEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:GJESDAL
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:410 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2680
Mailing Address - Country:US
Mailing Address - Phone:406-257-1336
Mailing Address - Fax:406-257-1353
Practice Address - Street 1:410 WINDWARD WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2680
Practice Address - Country:US
Practice Address - Phone:406-257-1336
Practice Address - Fax:406-257-1353
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000255527Medicaid