Provider Demographics
NPI:1336607043
Name:HANSEN, AMBERLY JILL (SUDC-I)
Entity Type:Individual
Prefix:
First Name:AMBERLY
Middle Name:JILL
Last Name:HANSEN
Suffix:
Gender:F
Credentials:SUDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 WASHINGTON BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-3606
Mailing Address - Country:US
Mailing Address - Phone:801-233-8670
Mailing Address - Fax:
Practice Address - Street 1:2661 WASHINGTON BLVD STE 102
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3606
Practice Address - Country:US
Practice Address - Phone:801-233-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)