Provider Demographics
NPI:1871068304
Name:HAGERSTROM, KELLY CABRAL (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CABRAL
Last Name:HAGERSTROM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:CABRAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1061 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-6728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1061 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-6728
Practice Address - Country:US
Practice Address - Phone:508-996-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health