Provider Demographics
NPI:1619067600
Name:HANSEN, PETER JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 N GRANDVIEW BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1672
Mailing Address - Country:US
Mailing Address - Phone:414-303-4205
Mailing Address - Fax:
Practice Address - Street 1:2717 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1672
Practice Address - Country:US
Practice Address - Phone:414-303-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2072057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39130500Medicaid
WI39130500Medicaid
WI000044785Medicare PIN
WI000044790Medicare PIN