Provider Demographics
NPI:1073158200
Name:HANSEN, STEPHEN CHARLES (PSYD, LCP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHARLES
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PSYD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 W LAWN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62681-1648
Mailing Address - Country:US
Mailing Address - Phone:312-213-3926
Mailing Address - Fax:
Practice Address - Street 1:428 W LAWN ST APT 2
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62681-1648
Practice Address - Country:US
Practice Address - Phone:312-213-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010171103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical