Healthcare Provider Details

I. General information

NPI: 1811205438
Provider Name (Legal Business Name): PAUL MATTHEW HANSEN LPCC #1845
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 KERNER BLVD STE A
SAN RAFAEL CA
94901-4840
US

IV. Provider business mailing address

3270 KERNER BLVD STE A
SAN RAFAEL CA
94901-4840
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-2879
  • Fax: 415-473-6313
Mailing address:
  • Phone: 415-473-2879
  • Fax: 415-473-6313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1845
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1504
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: