Provider Demographics
NPI:1205187606
Name:CLAIRMONT-HANSEN, MARY JO (MED LPC)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:CLAIRMONT-HANSEN
Suffix:
Gender:F
Credentials:MED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 FIECHTNER DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2358
Practice Address - Country:US
Practice Address - Phone:701-293-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2016-08-30
Deactivation Date:2015-02-19
Deactivation Code:
Reactivation Date:2016-08-29
Provider Licenses
StateLicense IDTaxonomies
ND1723101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)