Provider Demographics
NPI:1235397381
Name:HANSEN, BRENDA JEAN
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:JEAN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9021 EKLUND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55711-8005
Mailing Address - Country:US
Mailing Address - Phone:218-453-5684
Mailing Address - Fax:
Practice Address - Street 1:425 6TH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:FLOODWOOD
Practice Address - State:MN
Practice Address - Zip Code:55736
Practice Address - Country:US
Practice Address - Phone:218-390-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN830452261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities