MEDICARE: DR. BLAKE DARRELL HANSEN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	11235836-2506	UT

General Provider Information

NPI Number	:	1306350186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE DARRELL HANSEN PHD

Provider Business Mailing Address
First Line	:	1609 W 50 N
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-3565
Country	:	US
Telephone Number	:	801-419-5899
Fax Number	:

Provider Business Practice Location Address
First Line	:	1609 W 50 N
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-3565
Country	:	US
Telephone Number	:	801-419-5899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	01/21/2021

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