Provider Demographics
NPI:1255504379
Name:HANSON, MARK (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1914
Mailing Address - Country:US
Mailing Address - Phone:701-476-7208
Mailing Address - Fax:701-476-7261
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1914
Practice Address - Country:US
Practice Address - Phone:701-476-7208
Practice Address - Fax:701-476-7261
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND409103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist