Provider Demographics
NPI:1861512287
Name:HAGEN, BEVERLY JEAN
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:JEAN
Last Name:HAGEN
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 1:2900 W RUMBLE RD
Mailing Address - Street 2:#20
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0193
Mailing Address - Country:US
Mailing Address - Phone:209-236-1025
Mailing Address - Fax:
Practice Address - Street 1:801 11TH STREET
Practice Address - Street 2:SUITE B100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2324
Practice Address - Country:US
Practice Address - Phone:209-567-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)