Provider Demographics
NPI:1417412560
Name:HANSEN, ALYSSA RAE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:RAE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 N WASHINGTON BLVD APT C105
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3986
Mailing Address - Country:US
Mailing Address - Phone:801-678-5975
Mailing Address - Fax:
Practice Address - Street 1:358 S 700 E STE B307
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2161
Practice Address - Country:US
Practice Address - Phone:801-935-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-03
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician