Provider Demographics
NPI:1720502883
Name:HAGSTROM, CARL GLENN (MSW)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:GLENN
Last Name:HAGSTROM
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130223
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48113-0223
Mailing Address - Country:US
Mailing Address - Phone:734-222-5040
Mailing Address - Fax:734-929-4415
Practice Address - Street 1:342 S ASHLEY ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1351
Practice Address - Country:US
Practice Address - Phone:734-222-5040
Practice Address - Fax:734-929-4415
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010712861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical