Healthcare Provider Details

I. General information

NPI: 1871867549
Provider Name (Legal Business Name): STACIA HANSON MA LP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 YORK AVE S SUITE 317
EDINA MN
55435
US

IV. Provider business mailing address

7101 YORK AVE S SUITE 317
EDINA MN
55435
US

V. Phone/Fax

Practice location:
  • Phone: 952-921-3266
  • Fax: 651-224-3765
Mailing address:
  • Phone: 952-921-3266
  • Fax: 651-224-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: STACIA HANSON
Title or Position: CEO, OWNER
Credential: MA LP
Phone: 952-921-3266