Provider Demographics
NPI:1962044545
Name:HAGEN, MISTIE MICHELL (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MISTIE
Middle Name:MICHELL
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WELLINGTON OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-5571
Mailing Address - Country:US
Mailing Address - Phone:940-395-5663
Mailing Address - Fax:
Practice Address - Street 1:3605 YUCCA DR
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2755
Practice Address - Country:US
Practice Address - Phone:972-874-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist