Provider Demographics
NPI:1124100797
Name:HAGEN, SHANNON KEGLEY (DPT, PT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KEGLEY
Last Name:HAGEN
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 OVERLAND AVE STE E
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-7450
Mailing Address - Country:US
Mailing Address - Phone:406-534-4515
Mailing Address - Fax:
Practice Address - Street 1:2675 OVERLAND AVE STE E
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-7450
Practice Address - Country:US
Practice Address - Phone:406-534-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7768225100000X
MT21755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist