Provider Demographics
NPI:1881734671
Name:HAGAN, LORI ELIZABETH (PTA)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ELIZABETH
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 COLO TRL
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4864
Mailing Address - Country:US
Mailing Address - Phone:615-941-1728
Mailing Address - Fax:
Practice Address - Street 1:515 STONECREST PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6826
Practice Address - Country:US
Practice Address - Phone:615-220-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2574225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant