Provider Demographics
NPI:1356820732
Name:HAGEWOOD, ANITA ROSE (LICENSED PSYCH TECH)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:ROSE
Last Name:HAGEWOOD
Suffix:
Gender:F
Credentials:LICENSED PSYCH TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 COURAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6717
Mailing Address - Country:US
Mailing Address - Phone:707-253-7015
Mailing Address - Fax:
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6717
Practice Address - Country:US
Practice Address - Phone:707-253-7015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18280167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician