Provider Demographics
NPI:1801083928
Name:HAGSTROM, TERRI A (LCSW)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:A
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:100 E MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-6041
Mailing Address - Country:US
Mailing Address - Phone:541-789-5526
Mailing Address - Fax:541-789-5203
Practice Address - Street 1:600 S 2ND ST
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2704
Practice Address - Country:US
Practice Address - Phone:541-789-4000
Practice Address - Fax:541-789-4023
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL39141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical