Provider Demographics
NPI:1710571542
Name:HAGAN, ALLYSON LOUISE (CTRS)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:LOUISE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:LOUISE
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS
Mailing Address - Street 1:443 KEMPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4797
Mailing Address - Country:US
Mailing Address - Phone:757-455-6158
Mailing Address - Fax:
Practice Address - Street 1:443 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4797
Practice Address - Country:US
Practice Address - Phone:757-455-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
62743OtherNATIONAL COUNCIL FOR THERAPEUTIC RECREATION CERTIFICATION