Basic Information
| Provider Information | |||||||||
| NPI: | 1013038942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | NADINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEIZER | ||||||||
| OtherFirstName: | NADINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 807 16TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | TURTLE LAKE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585759443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014482140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 BURDICK EXPY W | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575514 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 136 | NE | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 01751T | IA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 1010 | ND | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.