Provider Demographics
NPI:1780657072
Name:HAGEN, GRACE ANN (MPT)
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:ANN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 LACLEDE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-531-8148
Mailing Address - Fax:314-531-5874
Practice Address - Street 1:4150 LACLEDE
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-531-8148
Practice Address - Fax:314-531-5874
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010065572251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics