Provider Demographics
NPI:1023533528
Name:HAGEN, KRISTINE LYNN (MS, CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LYNN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E LORENA AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-2123
Mailing Address - Country:US
Mailing Address - Phone:618-254-0607
Mailing Address - Fax:
Practice Address - Street 1:501 E LORENA AVE
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-2123
Practice Address - Country:US
Practice Address - Phone:618-254-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist