Provider Demographics
NPI:1407189251
Name:JOHN HANSEN M.A. LICENSED PSYCHOLOGIST LLC
Entity Type:Organization
Organization Name:JOHN HANSEN M.A. LICENSED PSYCHOLOGIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:651-434-3325
Mailing Address - Street 1:1600 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3898
Mailing Address - Country:US
Mailing Address - Phone:651-434-3325
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 400
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3898
Practice Address - Country:US
Practice Address - Phone:651-434-3325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3679103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN795217100Medicaid