Provider Demographics
NPI:1063493823
Name:HAGEN, STACEY JEAN (LCSWC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JEAN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 RITCHIE HWY
Mailing Address - Street 2:STE F
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-2742
Mailing Address - Country:US
Mailing Address - Phone:410-757-2077
Mailing Address - Fax:410-757-5184
Practice Address - Street 1:49 OLD SOLOMONS ISLAND RD
Practice Address - Street 2:STE 303
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3854
Practice Address - Country:US
Practice Address - Phone:410-573-1944
Practice Address - Fax:410-573-1972
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2010-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08288104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD222L1120Medicare ID - Type Unspecified