Provider Demographics
NPI:1871032581
Name:HAGAN, KIM (MA/SLP,CCC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MA/SLP,CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1967
Mailing Address - Country:US
Mailing Address - Phone:270-402-2379
Mailing Address - Fax:
Practice Address - Street 1:440 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1967
Practice Address - Country:US
Practice Address - Phone:270-402-2379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY342553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist