Provider Demographics
NPI:1225543143
Name:HANSON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HANSON
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 1:2195 BRANDYWYN LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6694
Mailing Address - Country:US
Mailing Address - Phone:847-955-3586
Mailing Address - Fax:
Practice Address - Street 1:2195 BRANDYWYN LN
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6694
Practice Address - Country:US
Practice Address - Phone:847-955-3586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool