Provider Demographics
NPI:1629779012
Name:HAGEMAN, KEITH (MS, PPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:HAGEMAN
Suffix:
Gender:M
Credentials:MS, PPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 BLACKMORE RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-262-5118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional