Provider Demographics
NPI:1396800819
Name:COLLEEN L HAGAN LCSW INC
Entity type:Organization
Organization Name:COLLEEN L HAGAN LCSW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-469-1409
Mailing Address - Street 1:1640 POWERS FERRY RD SE
Mailing Address - Street 2:BLDG 29 SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5491
Mailing Address - Country:US
Mailing Address - Phone:678-469-1409
Mailing Address - Fax:770-858-1700
Practice Address - Street 1:1640 POWERS FERRY RD SE
Practice Address - Street 2:BLDG 29 SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:678-469-1409
Practice Address - Fax:770-858-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0013791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA089005OtherVALUE OPTIONS
GA1295714442OtherNPI COLLEEN L HAGAN INDIV
GAGRP5193Medicare ID - Type Unspecified
GA1295714442OtherNPI COLLEEN L HAGAN INDIV
GAP63031Medicare UPIN