Provider Demographics
NPI:1902135262
Name:HAGAN, DIANE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:CANTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7443 S RIVER BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:IN
Mailing Address - Zip Code:47243-9336
Mailing Address - Country:US
Mailing Address - Phone:812-866-5455
Mailing Address - Fax:
Practice Address - Street 1:7443 S RIVER BOTTOM RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IN
Practice Address - Zip Code:47243-9336
Practice Address - Country:US
Practice Address - Phone:812-866-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003127A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist