Provider Demographics
NPI:1881051928
Name:HAGEN, LAURIE (LSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:HAGEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2055
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58402-2055
Mailing Address - Country:US
Mailing Address - Phone:701-253-6300
Mailing Address - Fax:701-253-6400
Practice Address - Street 1:520 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3016
Practice Address - Country:US
Practice Address - Phone:701-253-6300
Practice Address - Fax:701-253-6400
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12202101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator