Provider Demographics
NPI:1740957737
Name:HAGSTROM, CARRIE (MS, BACB, LBA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:MS, BACB, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1071
Mailing Address - Country:US
Mailing Address - Phone:410-381-7171
Mailing Address - Fax:410-381-4480
Practice Address - Street 1:6505 RIDENOUR WAY E
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6557
Practice Address - Country:US
Practice Address - Phone:410-381-7171
Practice Address - Fax:410-381-4480
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA786103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst