Provider Demographics
NPI:1073291886
Name:HAGEN, RACHEL SUZANNE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:SUZANNE
Last Name:HAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4152 30TH AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8403
Mailing Address - Country:US
Mailing Address - Phone:701-364-2663
Mailing Address - Fax:
Practice Address - Street 1:5354 42ND ST S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4032
Practice Address - Country:US
Practice Address - Phone:701-501-8014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND106S00000X
ND6519104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician