Provider Demographics
NPI:1508867649
Name:HANSEN, GARY DOUGLAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DOUGLAS
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 GOODYEAR AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6438
Mailing Address - Country:US
Mailing Address - Phone:805-650-8008
Mailing Address - Fax:805-650-6533
Practice Address - Street 1:1501 GOODYEAR AVE
Practice Address - Street 2:SUITE D
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6438
Practice Address - Country:US
Practice Address - Phone:805-650-8008
Practice Address - Fax:805-650-6533
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS37401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW3740AMedicare ID - Type Unspecified