Provider Demographics
NPI:1023738804
Name:HANSEN, ANNA MARIE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5186 SCORESBY AVE
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-5015
Mailing Address - Country:US
Mailing Address - Phone:208-520-8392
Mailing Address - Fax:
Practice Address - Street 1:5186 SCORESBY AVE
Practice Address - Street 2:
Practice Address - City:IONA
Practice Address - State:ID
Practice Address - Zip Code:83427-5015
Practice Address - Country:US
Practice Address - Phone:208-520-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0009941Medicaid