Provider Demographics
NPI:1639942824
Name:HANSON, BRIAN JAMES (PHD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:HANSON
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 1:33 BASS CT
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2610
Mailing Address - Country:US
Mailing Address - Phone:631-513-5437
Mailing Address - Fax:
Practice Address - Street 1:5225 NESCONSET HWY STE 1
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2054
Practice Address - Country:US
Practice Address - Phone:631-828-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP122183103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical