Provider Demographics
NPI:1174720320
Name:HAGEN, CHARLOTTE A (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:A
Last Name:HAGEN
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 1:2018 W RIVERSIDE AVE
Mailing Address - Street 2:APT. A
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-1411
Mailing Address - Country:US
Mailing Address - Phone:509-624-0528
Mailing Address - Fax:
Practice Address - Street 1:414 S UNIVERSITY RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-5555
Practice Address - Country:US
Practice Address - Phone:509-924-4650
Practice Address - Fax:509-228-0851
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003981235Z00000X
IDSLP-1108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist