Provider Demographics
NPI:1003347030
Name:HANSEN, SHANYN
Entity Type:Individual
Prefix:
First Name:SHANYN
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 COALING RD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-6413
Mailing Address - Country:US
Mailing Address - Phone:540-312-6057
Mailing Address - Fax:
Practice Address - Street 1:296 COALING RD
Practice Address - Street 2:
Practice Address - City:TROUTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24175-6413
Practice Address - Country:US
Practice Address - Phone:540-312-6057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABACB291360106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician