Provider Demographics
NPI:1346257813
Name:HAGER, JOHANNA M (LCPC, DBCFC)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:M
Last Name:HAGER
Suffix:
Gender:F
Credentials:LCPC, DBCFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-0116
Mailing Address - Country:US
Mailing Address - Phone:309-945-5739
Mailing Address - Fax:
Practice Address - Street 1:698 OAKWOOD PL
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1916
Practice Address - Country:US
Practice Address - Phone:309-945-5739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03732026OtherBCBS OF ILLINOIS