Provider Demographics
NPI:1083367932
Name:HAGSTROM, SHAUNA (BCBA)
Entity Type:Individual
Prefix:MS
First Name:SHAUNA
Middle Name:
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PETERBOROUGH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:JAFFREY
Mailing Address - State:NH
Mailing Address - Zip Code:03452-6808
Mailing Address - Country:US
Mailing Address - Phone:603-562-6437
Mailing Address - Fax:
Practice Address - Street 1:40 PETERBOROUGH ST APT 3
Practice Address - Street 2:
Practice Address - City:JAFFREY
Practice Address - State:NH
Practice Address - Zip Code:03452-6808
Practice Address - Country:US
Practice Address - Phone:603-562-6437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1-21-54901103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst