Provider Demographics
NPI:1518020726
Name:HAGEN, HEIDI J (PTA)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:J
Last Name:HAGEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:HEIDI
Other - Middle Name:J
Other - Last Name:KOONTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3024 N SILVERADO
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1040
Mailing Address - Country:US
Mailing Address - Phone:602-697-1085
Mailing Address - Fax:
Practice Address - Street 1:2835 E BROWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5470
Practice Address - Country:US
Practice Address - Phone:480-807-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0213A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant