Provider Demographics
NPI:1083805246
Name:HAGSTROM, HOLLY H (LPC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:H
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61051 E SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4402
Mailing Address - Country:US
Mailing Address - Phone:715-682-6266
Mailing Address - Fax:715-682-3526
Practice Address - Street 1:405 LAKE SHORE DR E
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1837
Practice Address - Country:US
Practice Address - Phone:715-682-3523
Practice Address - Fax:715-682-3526
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3556-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41001100Medicaid