Provider Demographics
NPI:1346610532
Name:HANSEN, MARY ROBERTA (BS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ROBERTA
Last Name:HANSEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 GARDEN PARK TER
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6744
Mailing Address - Country:US
Mailing Address - Phone:920-448-6328
Mailing Address - Fax:920-448-6065
Practice Address - Street 1:111 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5005
Practice Address - Country:US
Practice Address - Phone:920-448-6328
Practice Address - Fax:920-448-6065
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1684-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker