Provider Demographics
NPI:1982975876
Name:HAGEN, BETH ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:PRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:345 BROADWAY NW
Mailing Address - Street 2:
Mailing Address - City:MCINTOSH
Mailing Address - State:MN
Mailing Address - Zip Code:56556
Mailing Address - Country:US
Mailing Address - Phone:602-707-2200
Mailing Address - Fax:
Practice Address - Street 1:1225 W CLARENDON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-707-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN190621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical