Provider Demographics
NPI:1841285491
Name:HANSELL, PHYLLIS S (EDD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:S
Last Name:HANSELL
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 73RD ST
Mailing Address - Street 2:STE 5
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50311-1321
Mailing Address - Country:US
Mailing Address - Phone:515-222-1175
Mailing Address - Fax:515-222-0953
Practice Address - Street 1:1000 73RD ST
Practice Address - Street 2:STE 5
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50311-1321
Practice Address - Country:US
Practice Address - Phone:515-222-1175
Practice Address - Fax:515-222-0953
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA326103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0040428Medicaid
IA06931Medicare ID - Type Unspecified