Provider Demographics
NPI:1992802714
Name:HAGNER, THOMAS (LICSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HAGNER
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:8611 W POINT DOUGLAS RD S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4005
Practice Address - Country:US
Practice Address - Phone:651-458-1884
Practice Address - Fax:651-241-0345
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9831041C0700X
MN336191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH020258994-43OtherHARVARD PILGRIM
NH14Y001069NH01OtherBLUE CROSS
NH2035549OtherCIGNA
NHRE7483Medicare ID - Type Unspecified