Provider Demographics
NPI:1225465156
Name:HANSEN, MARK ANDREW (LPCC 15352)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LPCC 15352
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:ANDREW
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:1470 BLUEGRASS LN
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-9245
Mailing Address - Country:US
Mailing Address - Phone:925-209-8546
Mailing Address - Fax:
Practice Address - Street 1:1470 BLUEGRASS LN
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-9245
Practice Address - Country:US
Practice Address - Phone:925-209-8546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-10
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH1012021917101YA0400X
CA15352101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)