Provider Demographics
NPI:1639204159
Name:HANSEN, MICHAEL S (MPT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 WESTRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-9120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 N WORTHEN ST
Practice Address - Street 2:STE 200
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6137
Practice Address - Country:US
Practice Address - Phone:509-665-3156
Practice Address - Fax:509-665-0414
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA122973Medicaid
WA99719OtherLABOR & INDUSTRIES
WA99719OtherLABOR & INDUSTRIES