Provider Demographics
NPI:1851472930
Name:HAGEN, NICOLE M (SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:HAGEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:NICODEMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2679 WIHEGA RD
Mailing Address - Street 2:
Mailing Address - City:ARBOR VITAE
Mailing Address - State:WI
Mailing Address - Zip Code:54568-8802
Mailing Address - Country:US
Mailing Address - Phone:715-356-5989
Mailing Address - Fax:
Practice Address - Street 1:2679 WIHEGA RD
Practice Address - Street 2:
Practice Address - City:ARBOR VITAE
Practice Address - State:WI
Practice Address - Zip Code:54568-8802
Practice Address - Country:US
Practice Address - Phone:715-356-5989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2572-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42561400Medicaid