Provider Demographics
NPI:1346796810
Name:HAGEDORN, MICHAEL G (LCAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 W DELAWARE ST STE 217
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1667
Mailing Address - Country:US
Mailing Address - Phone:812-499-7950
Mailing Address - Fax:
Practice Address - Street 1:734 W DELAWARE ST STE 217
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1667
Practice Address - Country:US
Practice Address - Phone:812-499-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001568A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)