Provider Demographics
NPI:1588786180
Name:HAGAN, REBECCA (CCC, SLP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15247 DUPONT PATH
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124
Mailing Address - Country:US
Mailing Address - Phone:612-423-4852
Mailing Address - Fax:
Practice Address - Street 1:15247 DUPONT PATH
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124
Practice Address - Country:US
Practice Address - Phone:612-423-4852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12097902235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist