Provider Demographics
NPI:1124657408
Name:HAGAN, MICHAEL JOHN (LMFT #131272)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:HAGAN
Suffix:
Gender:M
Credentials:LMFT #131272
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191614
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92159-1614
Mailing Address - Country:US
Mailing Address - Phone:619-565-4494
Mailing Address - Fax:
Practice Address - Street 1:2469 C ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2019
Practice Address - Country:US
Practice Address - Phone:619-565-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131272106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist