Provider Demographics
NPI:1326247925
Name:HAGGERTY, KATHLEEN M (MSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:HAGGERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:520 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3838
Mailing Address - Country:US
Mailing Address - Phone:810-984-4202
Mailing Address - Fax:810-984-8896
Practice Address - Street 1:520 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3838
Practice Address - Country:US
Practice Address - Phone:810-984-4202
Practice Address - Fax:810-984-8896
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010734611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G46345Medicare PIN