Provider Demographics
NPI:1972588473
Name:HANSEN, MARK P (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
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 1:1360 ENERGY PARK DR
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5276
Mailing Address - Country:US
Mailing Address - Phone:651-646-8985
Mailing Address - Fax:651-646-3959
Practice Address - Street 1:1360 ENERGY PARK DR
Practice Address - Street 2:SUITE 340
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5276
Practice Address - Country:US
Practice Address - Phone:651-646-8985
Practice Address - Fax:651-646-3959
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1440103TC1900X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN42GI3HAOtherBLUE CROSS& BLUE SHEILD
MN01009904OtherPREFERRED ONE
MN643353700Medicaid