Provider Demographics
NPI:1194043885
Name:HAGENESS, HAILEY DAWN (MSOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:HAILEY
Middle Name:DAWN
Last Name:HAGENESS
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 45TH ST
Mailing Address - Street 2:UNIT F
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-1172
Mailing Address - Country:US
Mailing Address - Phone:989-621-5197
Mailing Address - Fax:
Practice Address - Street 1:1235 S 24TH ST
Practice Address - Street 2:ATTN REHABCARE
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5516
Practice Address - Country:US
Practice Address - Phone:920-682-8254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4872-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist