Provider Demographics
NPI:1730500950
Name:HANSEN, MARY MARIE (MA, CCC-ALP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARIE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MA, CCC-ALP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3936 WASHINGTON AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:WI
Mailing Address - Zip Code:54130-6901
Mailing Address - Country:US
Mailing Address - Phone:605-321-5378
Mailing Address - Fax:
Practice Address - Street 1:107 E BECKERT RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2509
Practice Address - Country:US
Practice Address - Phone:920-982-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14072042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist