Provider Demographics
NPI:1164727871
Name:HAGAN, MARY CECIL (OTR/ L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CECIL
Last Name:HAGAN
Suffix:
Gender:F
Credentials:OTR/ L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9817 WHITE BLOSSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-4181
Mailing Address - Country:US
Mailing Address - Phone:502-295-8673
Mailing Address - Fax:
Practice Address - Street 1:2615 MCCOY WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2361
Practice Address - Country:US
Practice Address - Phone:502-552-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4368172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker