Provider Demographics
NPI:1851573687
Name:HAGBERG, MARYANN E (RD,CDN)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:E
Last Name:HAGBERG
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 SABAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2166
Mailing Address - Country:US
Mailing Address - Phone:203-591-1644
Mailing Address - Fax:
Practice Address - Street 1:130 DIVISION ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1326
Practice Address - Country:US
Practice Address - Phone:203-732-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000814132700000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060647014OtherGRIFFIN HOSPITAL FEDERAL TAX ID NUMBER