Provider Demographics
NPI:1891128690
Name:HAGEN, SAMANTHA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LAING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 W LIBERTY RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9746
Mailing Address - Country:US
Mailing Address - Phone:734-780-7852
Mailing Address - Fax:
Practice Address - Street 1:3200 W LIBERTY RD
Practice Address - Street 2:SUITE F
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9746
Practice Address - Country:US
Practice Address - Phone:734-780-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005323235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist