Provider Demographics
NPI:1477209211
Name:HAGENS, CHARLOTTE M (MT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:M
Last Name:HAGENS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 CAVALCADE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7126
Mailing Address - Country:US
Mailing Address - Phone:817-821-4938
Mailing Address - Fax:
Practice Address - Street 1:1106 CAVALCADE DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7126
Practice Address - Country:US
Practice Address - Phone:817-821-4938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT038948225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty