Healthcare Provider Details

I. General information

NPI: 1588198295
Provider Name (Legal Business Name): MICHAEL HANSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

IV. Provider business mailing address

1648 ASH AVE
WOODSTOCK IL
60098-2589
US

V. Phone/Fax

Practice location:
  • Phone: 312-617-6230
  • Fax: 708-747-7999
Mailing address:
  • Phone: 815-307-2539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.006986
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: