Provider Demographics
NPI:1093269045
Name:HANSEN, PARKER
Entity Type:Individual
Prefix:
First Name:PARKER
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3815
Mailing Address - Country:US
Mailing Address - Phone:619-692-8750
Mailing Address - Fax:619-692-8779
Practice Address - Street 1:1250 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3815
Practice Address - Country:US
Practice Address - Phone:619-692-8750
Practice Address - Fax:619-692-8779
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program