Provider Demographics
NPI:1235456633
Name:HAGAN, ELAINE TUCKER (MA SLP CCC)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:TUCKER
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MA SLP CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-4285
Mailing Address - Country:US
Mailing Address - Phone:757-692-6574
Mailing Address - Fax:
Practice Address - Street 1:5804 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4813
Practice Address - Country:US
Practice Address - Phone:757-692-6574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004878235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235456633Medicaid