Provider Demographics
NPI:1114910049
Name:HEGEMAN, GAIL (PH D)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:
Last Name:HEGEMAN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:DR
Other - First Name:GAIL
Other - Middle Name:M
Other - Last Name:HEGEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH D
Mailing Address - Street 1:1711 COUNTY ROAD B WEST
Mailing Address - Street 2:SUITE 144S
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4100
Mailing Address - Country:US
Mailing Address - Phone:651-635-0909
Mailing Address - Fax:612-822-8669
Practice Address - Street 1:1711 COUNTY ROAD B WEST
Practice Address - Street 2:SUITE 144S
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4100
Practice Address - Country:US
Practice Address - Phone:651-635-0909
Practice Address - Fax:612-822-8669
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2464103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
30269000OtherMAGELLAN BEHAVIOR HEALTH
MN59123AROtherBCBS
MN59125HEOtherBCBS
MN642047800Medicaid
MN6113193OtherUNITED BEHAVIORAL HEALTH
MN59125HEOtherBCBS