Healthcare Provider Details

I. General information

NPI: 1962481762
Provider Name (Legal Business Name): MARY BETH HANSON L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E CALL ST
ALGONA IA
50511-2444
US

IV. Provider business mailing address

117 E CALL ST
ALGONA IA
50511-2444
US

V. Phone/Fax

Practice location:
  • Phone: 515-295-4315
  • Fax: 515-395-3315
Mailing address:
  • Phone: 515-295-4315
  • Fax: 515-395-3315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00742
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier099333000
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerMAGELLAN HEALTH VENDOR NU
# 2
Identifier1143784
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: