Provider Demographics
NPI:1497262174
Name:HANSEN, STEVEN
Entity Type:Individual
Prefix:
First Name:STEVEN
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 1:112 NE MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1109
Mailing Address - Country:US
Mailing Address - Phone:309-674-7874
Mailing Address - Fax:
Practice Address - Street 1:2338 W VAN WINKLE WAY STE 3100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7483
Practice Address - Country:US
Practice Address - Phone:309-693-9189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008307225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056008307OtherPROFESSIONAL LICENSE