Provider Demographics
NPI:1114375045
Name:HANSEN, MOLLIE
Entity Type:Individual
Prefix:
First Name:MOLLIE
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 1:5301 TIETON DR STE C
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3479
Mailing Address - Country:US
Mailing Address - Phone:509-965-7100
Mailing Address - Fax:509-966-9750
Practice Address - Street 1:5301 TIETON DR STE C
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908
Practice Address - Country:US
Practice Address - Phone:509-965-7100
Practice Address - Fax:509-966-9750
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAB60925122106E00000X
WAG60655200101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2061184Medicaid