Provider Demographics
NPI:1457589731
Name:HAGEN, KELLI L (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:HAGEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:L
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8550 MARSHALL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1505
Mailing Address - Country:US
Mailing Address - Phone:913-894-1500
Mailing Address - Fax:913-647-0295
Practice Address - Street 1:8550 MARSHALL DR
Practice Address - Street 2:STE 100
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66214-1505
Practice Address - Country:US
Practice Address - Phone:913-894-1500
Practice Address - Fax:913-647-0295
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-039822251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
42826014OtherBLUECROSS BLUE SHEILD KC
P00975021OtherMEDICARE RAILROAD
623B00003Medicare PIN