Provider Demographics
NPI:1306363932
Name:HEGSTROM, CHARLES P (MA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:P
Last Name:HEGSTROM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 S IH 35 STE 210
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2603
Mailing Address - Country:US
Mailing Address - Phone:512-343-8606
Mailing Address - Fax:
Practice Address - Street 1:1524 S IH 35 STE 210
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-2603
Practice Address - Country:US
Practice Address - Phone:512-343-8606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator