Provider Demographics
NPI:1437281508
Name:HAGEN, DIANE WENDY (MPT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:WENDY
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12088 MARGARET ROSE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4052
Mailing Address - Country:US
Mailing Address - Phone:801-232-9242
Mailing Address - Fax:
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-3454
Practice Address - Country:US
Practice Address - Phone:801-840-2191
Practice Address - Fax:801-840-2197
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5148443-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist