Provider Demographics
NPI:1376083576
Name:HANSON, SANDRA JEAN (LADC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:HANSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2738
Mailing Address - Country:US
Mailing Address - Phone:218-287-2089
Mailing Address - Fax:218-291-1250
Practice Address - Street 1:111 7TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2738
Practice Address - Country:US
Practice Address - Phone:218-287-2089
Practice Address - Fax:218-291-1250
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300070101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)