Provider Demographics
NPI:1720251390
Name:HAGENLOCK, MICHAEL ERIC SR (MSW, LAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:HAGENLOCK
Suffix:SR
Gender:M
Credentials:MSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W MADISON AVE STE 301
Mailing Address - Street 2:PO BOX 1288
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-3967
Mailing Address - Country:US
Mailing Address - Phone:406-388-7421
Mailing Address - Fax:
Practice Address - Street 1:201 W MADISON AVE STE 301
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-3967
Practice Address - Country:US
Practice Address - Phone:406-388-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1154-LAC101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health