Provider Demographics
NPI:1073605697
Name:HANSON, BRUCE R (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:HANSON
Suffix:
Gender:M
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 7TH AVE SOUTH
Mailing Address - Street 2:MSUM BOX 119
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56563-0001
Mailing Address - Country:US
Mailing Address - Phone:218-477-5953
Mailing Address - Fax:218-477-4392
Practice Address - Street 1:1104 7TH AVE SOUTH
Practice Address - Street 2:MSUM BOX 119
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563-0001
Practice Address - Country:US
Practice Address - Phone:218-477-4641
Practice Address - Fax:218-477-4392
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18427OtherBCBS
MN61B51HAOtherBCBS
ND51834Medicaid