Healthcare Provider Details

I. General information

NPI: 1669978045
Provider Name (Legal Business Name): HEIDI JEAN HANSEN TCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N EISENHOWER AVE
MASON CITY IA
50401-1521
US

IV. Provider business mailing address

35300 210TH AVE
FOREST CITY IA
50436-7667
US

V. Phone/Fax

Practice location:
  • Phone: 641-424-2391
  • Fax:
Mailing address:
  • Phone: 641-590-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT18015
License Number StateIA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: