Provider Demographics
NPI:1477868602
Name:HANSEN, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460993
Mailing Address - Street 2:480 N. MAIN STREET
Mailing Address - City:LEEDS
Mailing Address - State:UT
Mailing Address - Zip Code:84746-0993
Mailing Address - Country:US
Mailing Address - Phone:435-879-6990
Mailing Address - Fax:
Practice Address - Street 1:480 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:UT
Practice Address - Zip Code:84746-0993
Practice Address - Country:US
Practice Address - Phone:435-879-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT140877-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical