Provider Demographics
NPI:1760899181
Name:HANSEN, HAROLD (LMT)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 DEKALB AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3305
Mailing Address - Country:US
Mailing Address - Phone:815-895-3200
Mailing Address - Fax:815-991-9121
Practice Address - Street 1:1101 DEKALB AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3305
Practice Address - Country:US
Practice Address - Phone:815-895-3200
Practice Address - Fax:815-991-9121
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.005757225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist