Provider Demographics
NPI:1972131290
Name:HANSON, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:HANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 GUIDER DR APT 105
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-5344
Mailing Address - Country:US
Mailing Address - Phone:651-361-0025
Mailing Address - Fax:
Practice Address - Street 1:1394 JACKSON ST STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4669
Practice Address - Country:US
Practice Address - Phone:651-478-7815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304742101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)