Provider Demographics
NPI:1417170614
Name:HAGEDORN, CRISTIE LEE (OTRL)
Entity Type:Individual
Prefix:
First Name:CRISTIE
Middle Name:LEE
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5076 ELK FAIRWAYS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-2084
Mailing Address - Country:US
Mailing Address - Phone:513-894-3613
Mailing Address - Fax:
Practice Address - Street 1:3801 WOODRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-3598
Practice Address - Country:US
Practice Address - Phone:513-874-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT. 005080225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist