Provider Demographics
NPI:1568911857
Name:HAGERTY, MICHAEL (MA SLP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HAGERTY
Suffix:
Gender:M
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 N 62ND ST APT 207
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3075
Mailing Address - Country:US
Mailing Address - Phone:414-559-0203
Mailing Address - Fax:
Practice Address - Street 1:3200 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4442
Practice Address - Country:US
Practice Address - Phone:414-389-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4316-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist