Provider Demographics
NPI:1679204788
Name:HAGSTROM, EMILY WENDY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:WENDY
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9118
Mailing Address - Country:US
Mailing Address - Phone:651-424-4000
Mailing Address - Fax:
Practice Address - Street 1:721 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9118
Practice Address - Country:US
Practice Address - Phone:651-424-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician