Provider Demographics
NPI:1912145368
Name:HAGSTROM, AMY ELIZABETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:ELIZABETH
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 OHMS LN
Mailing Address - Street 2:SUITE 430
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2331
Mailing Address - Country:US
Mailing Address - Phone:612-226-8581
Mailing Address - Fax:
Practice Address - Street 1:7301 OHMS LN
Practice Address - Street 2:SUITE 430
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2331
Practice Address - Country:US
Practice Address - Phone:612-226-8581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5157103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical