Provider Demographics
NPI:1164632592
Name:HAGER, MARY J (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:J
Last Name:HAGER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 EDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1725
Mailing Address - Country:US
Mailing Address - Phone:304-776-4515
Mailing Address - Fax:
Practice Address - Street 1:200 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-2119
Practice Address - Country:US
Practice Address - Phone:304-348-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV005225X00000X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00401730121Medicaid