Provider Demographics
NPI:1235292731
Name:HAGSTROM, ROBERT STANSBURY JR (LCPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:STANSBURY
Last Name:HAGSTROM
Suffix:JR
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 GRAND AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-5857
Mailing Address - Country:US
Mailing Address - Phone:406-245-4005
Mailing Address - Fax:406-245-6441
Practice Address - Street 1:644 GRAND AVE
Practice Address - Street 2:STE 4
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-5800
Practice Address - Country:US
Practice Address - Phone:406-245-4005
Practice Address - Fax:406-245-6441
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT372101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT251888Medicaid