Provider Demographics
NPI:1700046497
Name:HAGAN, KERRY CARL (LMFT LPC)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:CARL
Last Name:HAGAN
Suffix:
Gender:M
Credentials:LMFT LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-3466
Mailing Address - Country:US
Mailing Address - Phone:903-757-6886
Mailing Address - Fax:903-757-6905
Practice Address - Street 1:441 N FREDONIA ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6427
Practice Address - Country:US
Practice Address - Phone:903-757-6886
Practice Address - Fax:903-757-6905
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16024101YP2500X
TX5010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional