Provider Demographics
NPI:1780745430
Name:PAGOAGA, TED M (MSW)
Entity type:Individual
Prefix:MR
First Name:TED
Middle Name:M
Last Name:PAGOAGA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:103 E MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1624
Mailing Address - Country:US
Mailing Address - Phone:605-873-3103
Mailing Address - Fax:608-873-1999
Practice Address - Street 1:W18105 HEMLOCK RD
Practice Address - Street 2:
Practice Address - City:WITTENBERG
Practice Address - State:WI
Practice Address - Zip Code:54499-8647
Practice Address - Country:US
Practice Address - Phone:715-253-2116
Practice Address - Fax:715-253-3586
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI65241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4092550Medicaid