Healthcare Provider Details

I. General information

NPI: 1891497384
Provider Name (Legal Business Name): WAITHIRA WANYEE HANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WAITHIRA WANYEE

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 MOUNTAIN DR STE 106
DESTIN FL
32541-2346
US

IV. Provider business mailing address

123 WRIGHT CIR
NICEVILLE FL
32578-4231
US

V. Phone/Fax

Practice location:
  • Phone: 850-837-9100
  • Fax:
Mailing address:
  • Phone: 781-864-5133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21945
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: