Provider Demographics
NPI:1497717508
Name:HAGEN, TED W II (DMIN PHD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:W
Last Name:HAGEN
Suffix:II
Gender:M
Credentials:DMIN PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SHERIDAN SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7399
Mailing Address - Country:US
Mailing Address - Phone:423-765-6276
Mailing Address - Fax:423-246-8278
Practice Address - Street 1:2 SHERIDAN SQ STE 200
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7399
Practice Address - Country:US
Practice Address - Phone:423-765-6276
Practice Address - Fax:423-246-8278
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0069106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3684645Medicaid
TN3684645Medicare ID - Type Unspecified