Provider Demographics
NPI:1770248148
Name:HANSON, THEO C (LCSW)
Entity type:Individual
Prefix:
First Name:THEO
Middle Name:C
Last Name:HANSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3141
Mailing Address - Country:US
Mailing Address - Phone:406-205-3433
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE STE 408
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3141
Practice Address - Country:US
Practice Address - Phone:406-205-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7313085Medicaid