Basic Information
| Provider Information | |||||||||
| NPI: | 1255986394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGEN | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAGEN | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AMFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1436 GOODRICH BLVD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900225111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237251337 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1436 GOODRICH BLVD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900225111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237251337 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2019 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 101651 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.