Provider Demographics
NPI:1295714442
Name:HAGAN, COLLEEN L
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:L
Last Name:HAGAN
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 1:1640 POWERS FERRY RD
Mailing Address - Street 2:BLDG 29, STE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5491
Mailing Address - Country:US
Mailing Address - Phone:770-956-9212
Mailing Address - Fax:770-956-9218
Practice Address - Street 1:1640 POWERS FERRY RD
Practice Address - Street 2:BLDG 29, STE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-956-9212
Practice Address - Fax:770-956-9218
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0013791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFQKMedicare ID - Type Unspecified
GAP63031Medicare UPIN