Provider Demographics
NPI:1821720822
Name:HANSEN, ANTHONY WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WAYNE
Last Name:HANSEN
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 1:3995 W COOPER LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-4006
Mailing Address - Country:US
Mailing Address - Phone:404-358-3200
Mailing Address - Fax:
Practice Address - Street 1:3995 W COOPER LAKE DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4006
Practice Address - Country:US
Practice Address - Phone:404-889-6886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004330103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling