Provider Demographics
NPI:1700324993
Name:HANSEN, DESTRY RONAE
Entity Type:Individual
Prefix:
First Name:DESTRY
Middle Name:RONAE
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 1:2009 SALERNO DR APT B
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1628
Mailing Address - Country:US
Mailing Address - Phone:907-209-6856
Mailing Address - Fax:
Practice Address - Street 1:2009 SALERNO DR APT B
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-1628
Practice Address - Country:US
Practice Address - Phone:907-209-6856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician