Provider Demographics
NPI:1760628937
Name:HAGEN, DAVID A (CHEMICAL DEPENDENCY)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:HAGEN
Suffix:
Gender:M
Credentials:CHEMICAL DEPENDENCY
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 219
Mailing Address - Street 2:
Mailing Address - City:TAHOLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98587-0219
Mailing Address - Country:US
Mailing Address - Phone:360-276-4405
Mailing Address - Fax:360-276-4474
Practice Address - Street 1:1505 KLA-OOK-WA
Practice Address - Street 2:
Practice Address - City:TAHOLAH
Practice Address - State:WA
Practice Address - Zip Code:98587-0219
Practice Address - Country:US
Practice Address - Phone:360-276-4405
Practice Address - Fax:360-276-4474
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001894101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1992817Medicaid