Provider Demographics
NPI:1508192261
Name:HAGEDORN, ERIN M (MS, ATC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:M
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EDGEWOOD ST
Mailing Address - Street 2:APT 3
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-3333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 SALISBURY ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1265
Practice Address - Country:US
Practice Address - Phone:508-767-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT 7652255A2300X
MA22612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer