Provider Demographics
NPI:1821487547
Name:HANSEN, ALISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SYLVAN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3115
Mailing Address - Country:US
Mailing Address - Phone:574-334-1118
Mailing Address - Fax:
Practice Address - Street 1:51728 INDIANA STATE ROUTE 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-1706
Practice Address - Country:US
Practice Address - Phone:574-298-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008218A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor