Provider Demographics
NPI:1285362236
Name:HAGAN, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 SHADY OAKS DR APT 200
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-2551
Mailing Address - Country:US
Mailing Address - Phone:610-755-7520
Mailing Address - Fax:
Practice Address - Street 1:454 FORT FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-9714
Practice Address - Country:US
Practice Address - Phone:610-755-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2025-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-25-83229103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician