Provider Demographics
NPI:1912404500
Name:HAGAN, SAMANTHA RHEA (BA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RHEA
Last Name:HAGAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707-N. 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:813-239-8069
Mailing Address - Fax:813-231-7324
Practice Address - Street 1:10500-UNIVERSITY CENTER DR. STE 215
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6490
Practice Address - Country:US
Practice Address - Phone:813-239-8069
Practice Address - Fax:813-231-7324
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-05-09
Deactivation Date:2018-04-12
Deactivation Code:
Reactivation Date:2018-04-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker