Provider Demographics
NPI:1457809543
Name:HAGENAU, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:HAGENAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY JANE
Other - Middle Name:
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:581 EMERALD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4545
Mailing Address - Country:US
Mailing Address - Phone:650-303-0305
Mailing Address - Fax:
Practice Address - Street 1:555 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2124
Practice Address - Country:US
Practice Address - Phone:650-690-2997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist