Provider Demographics
NPI:1477682748
Name:HANSEN, RICHARD (DPT, MS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPT, MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3955 OKEMOS RD
Practice Address - Street 2:SUITE B2
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4208
Practice Address - Country:US
Practice Address - Phone:517-349-4030
Practice Address - Fax:517-349-4031
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6211016Medicare UPIN
MIN69750064Medicare UPIN