Healthcare Provider Details

I. General information

NPI: 1417994690
Provider Name (Legal Business Name): MICHAEL H. HANSEN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

5001 HIGHWAY190 SUITE B1
COVINGTON LA
70433
US

V. Phone/Fax

Practice location:
  • Phone: 773-843-3000
  • Fax: 773-843-2704
Mailing address:
  • Phone: 985-590-5744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMP.0017
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: