Provider Demographics
NPI:1588782403
Name:HAGEN, ANGELA M (OT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:HAGEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:MOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11101 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9002
Mailing Address - Country:US
Mailing Address - Phone:608-884-1390
Mailing Address - Fax:
Practice Address - Street 1:11101 N SHERMAN RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9002
Practice Address - Country:US
Practice Address - Phone:608-884-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4401-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4401-026OtherOT LICENSE