Provider Demographics
NPI:1134828023
Name:HAGENBARTH, ANN M
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:HAGENBARTH
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 1:855 N DORYPORT CT
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4696
Mailing Address - Country:US
Mailing Address - Phone:208-691-4058
Mailing Address - Fax:
Practice Address - Street 1:855 N DORYPORT CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4696
Practice Address - Country:US
Practice Address - Phone:208-691-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID222Q00000XMedicaid