Provider Demographics
NPI:1073828521
Name:HAGMAN, AMANDA GEORGEANN
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:GEORGEANN
Last Name:HAGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11449 S 49TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-8947
Mailing Address - Country:US
Mailing Address - Phone:918-706-1847
Mailing Address - Fax:
Practice Address - Street 1:11449 S 49TH WEST AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-8947
Practice Address - Country:US
Practice Address - Phone:918-706-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation