Provider Demographics
NPI:1962481762
Name:HANSON, MARY BETH (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:HANSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E CALL ST
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:IA
Mailing Address - Zip Code:50511-2444
Mailing Address - Country:US
Mailing Address - Phone:515-295-4315
Mailing Address - Fax:515-395-3315
Practice Address - Street 1:117 E CALL ST
Practice Address - Street 2:
Practice Address - City:ALGONA
Practice Address - State:IA
Practice Address - Zip Code:50511-2444
Practice Address - Country:US
Practice Address - Phone:515-295-4315
Practice Address - Fax:515-395-3315
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA099333000OtherMAGELLAN HEALTH VENDOR NU
IA1143784Medicaid
IA42-1504365OtherTAX ID NUMBER