Provider Demographics
NPI:1427115914
Name:SPACKMAN, DAGNE HANSON (MS)
Entity type:Individual
Prefix:MRS
First Name:DAGNE
Middle Name:HANSON
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:DAGNE
Other - Middle Name:
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:140 S GILBERT ROAD
Mailing Address - Street 2:GILBERT PUBLIC SCHOOLS MEDICAID SBCP
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296
Mailing Address - Country:US
Mailing Address - Phone:602-301-6030
Mailing Address - Fax:
Practice Address - Street 1:3136 E SCORPIO PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-9644
Practice Address - Country:US
Practice Address - Phone:602-301-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0680235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ493700Medicaid