Provider Demographics
NPI:1316150550
Name:HAGE, MARYA O
Entity type:Individual
Prefix:
First Name:MARYA
Middle Name:O
Last Name:HAGE
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 1:831 W RIVER PKWY
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-1035
Mailing Address - Country:US
Mailing Address - Phone:763-427-1940
Mailing Address - Fax:
Practice Address - Street 1:9400 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4318
Practice Address - Country:US
Practice Address - Phone:763-450-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical