Provider Demographics
NPI:1235653254
Name:HAGAN, KELSEY NOEL
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:NOEL
Last Name:HAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1277
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:
Practice Address - Street 1:110 ROACH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9393
Practice Address - Country:US
Practice Address - Phone:502-863-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid