Provider Demographics
NPI:1083731483
Name:HANSEN, GARY W (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:HANSEN
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 1:605 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-1007
Mailing Address - Country:US
Mailing Address - Phone:712-362-3157
Mailing Address - Fax:
Practice Address - Street 1:1646 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-1760
Practice Address - Country:US
Practice Address - Phone:712-362-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist