Provider Demographics
NPI:1760105571
Name:HAGSTROM, NATALIE ALTHA MARIE
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:ALTHA MARIE
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 1:144 CANABURY CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1503
Mailing Address - Country:US
Mailing Address - Phone:763-439-9144
Mailing Address - Fax:
Practice Address - Street 1:3333 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3325
Practice Address - Country:US
Practice Address - Phone:612-331-9413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician