Provider Demographics
NPI:1578276671
Name:HAGOOD, HENRY CHARLES (DPT)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:CHARLES
Last Name:HAGOOD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8432
Mailing Address - Country:US
Mailing Address - Phone:509-362-2838
Mailing Address - Fax:
Practice Address - Street 1:1301 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4905
Practice Address - Country:US
Practice Address - Phone:406-721-0680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-24309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist