Provider Demographics
NPI:1528569662
Name:HAGEN, MISTY LYNN (LAC, LSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:LAC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 28TH ST S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8743
Mailing Address - Country:US
Mailing Address - Phone:701-404-1100
Mailing Address - Fax:
Practice Address - Street 1:901 28TH ST. SOUTH
Practice Address - Street 2:SUITE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-404-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5039104100000X
ND1837101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker