Provider Demographics
NPI:1578041091
Name:HANSEN, KELSEY (MAS-MFT, LMFT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MAS-MFT, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 E MISSOURI AVE STE 780
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2730
Mailing Address - Country:US
Mailing Address - Phone:602-777-6156
Mailing Address - Fax:
Practice Address - Street 1:1130 E MISSOURI AVE STE 780
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2730
Practice Address - Country:US
Practice Address - Phone:602-777-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-15241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist