Provider Demographics
NPI:1619075843
Name:HANSEN, JOHN MARTIN (LP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3898
Mailing Address - Country:US
Mailing Address - Phone:651-434-3325
Mailing Address - Fax:651-645-2752
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 229N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3679103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN795217100Medicaid