Provider Demographics
NPI:1932689221
Name:HAGAN, ADRIENNE (CCCSLPL)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:CCCSLPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 CREST VIEW WAY APT 3
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-5204
Mailing Address - Country:US
Mailing Address - Phone:970-242-6304
Mailing Address - Fax:
Practice Address - Street 1:1533 CREST VIEW WAY APT 3
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-5204
Practice Address - Country:US
Practice Address - Phone:970-242-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0001244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSLP.0001244OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES (DORA)