Provider Demographics
NPI:1710528021
Name:HANAGAN, PEGGY LORRAINE (COTA)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:LORRAINE
Last Name:HANAGAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4865 E TEPEE ST
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-8977
Mailing Address - Country:US
Mailing Address - Phone:518-268-9538
Mailing Address - Fax:
Practice Address - Street 1:1090 S GILBERT RD STE 106
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3439
Practice Address - Country:US
Practice Address - Phone:518-268-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006919224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant