Provider Demographics
NPI:1164958906
Name:HANSEN, TYLER (OTR)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6210
Mailing Address - Country:US
Mailing Address - Phone:208-490-0035
Mailing Address - Fax:
Practice Address - Street 1:2550 ADDISON AVE E STE D
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6749
Practice Address - Country:US
Practice Address - Phone:208-814-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTL- 1765225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist