Provider Demographics
NPI:1467757997
Name:HAGAN, ALISSA (RD)
Entity Type:Individual
Prefix:MISS
First Name:ALISSA
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 BEAUVOIR AVE
Mailing Address - Street 2:EATING DISORDERS UNIT
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3533
Mailing Address - Country:US
Mailing Address - Phone:908-522-4628
Mailing Address - Fax:
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:EATING DISORDERS UNIT
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:908-522-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1016027133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered