Provider Demographics
NPI:1750480679
Name:SMITH HANEN, SANDRA SUE (EDD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:SUE
Last Name:SMITH HANEN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2307
Mailing Address - Country:US
Mailing Address - Phone:612-722-1003
Mailing Address - Fax:612-721-6336
Practice Address - Street 1:4323 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2307
Practice Address - Country:US
Practice Address - Phone:612-722-1003
Practice Address - Fax:612-721-6336
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2754103T00000X, 103TF0200X, 103TB0200X, 103TC1900X, 103TA0700X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN100479OtherUCARE
MN6180090OtherMEDICA
MN064925MOtherBCBS
MN432747100Medicaid
MN064925MOtherBCBS
MN6180090OtherMEDICA