Provider Demographics
NPI:1962626887
Name:HAGE-THOMLEY, REBECCA S
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:S
Last Name:HAGE-THOMLEY
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 1:11580 STONERIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:55327-9570
Mailing Address - Country:US
Mailing Address - Phone:763-450-5045
Mailing Address - Fax:
Practice Address - Street 1:9400 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4318
Practice Address - Country:US
Practice Address - Phone:763-450-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2678103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO4232Medicare ID - Type Unspecified