Provider Demographics
NPI:1891537411
Name:HAGEN-ORTIZ, BREANA NICOLE (BS, BIS)
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:NICOLE
Last Name:HAGEN-ORTIZ
Suffix:
Gender:F
Credentials:BS, BIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 CHESTNUT ST APT B
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1155
Mailing Address - Country:US
Mailing Address - Phone:208-310-6682
Mailing Address - Fax:
Practice Address - Street 1:1620 CHESTNUT ST APT B
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1155
Practice Address - Country:US
Practice Address - Phone:208-310-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health