Healthcare Provider Details

I. General information

NPI: 1629142187
Provider Name (Legal Business Name): THOMAS R. HANSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 REED BLVD
MILL VALLEY CA
94941-2566
US

IV. Provider business mailing address

313 REED BLVD
MILL VALLEY CA
94941-2566
US

V. Phone/Fax

Practice location:
  • Phone: 415-336-6341
  • Fax:
Mailing address:
  • Phone: 415-336-6341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG85011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: