1518097443 NPI number — MYRIAH LEA HAGERMAN MA

Table of content: MYRIAH LEA HAGERMAN MA (NPI 1518097443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518097443 NPI number — MYRIAH LEA HAGERMAN MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGERMAN
Provider First Name:
MYRIAH
Provider Middle Name:
LEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518097443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2695 ROCKY MOUNTAIN AVE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-9071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-624-4128
Provider Business Mailing Address Fax Number:
970-490-4156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-2745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-584-4921
Provider Business Practice Location Address Fax Number:
719-595-7994
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , with the licence number:  6409 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 169944 . This is a "CPRP" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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