Provider Demographics
NPI:1710429907
Name:HAGEDORN, LESLIE A (LSW)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:A
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5618 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-5018
Mailing Address - Country:US
Mailing Address - Phone:812-568-1282
Mailing Address - Fax:
Practice Address - Street 1:734 W DELAWARE ST STE 217
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1667
Practice Address - Country:US
Practice Address - Phone:812-499-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-05
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99073814A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker