Healthcare Provider Details

I. General information

NPI: 1750480679
Provider Name (Legal Business Name): SANDRA SUE SMITH HANEN EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 E LAKE ST
MINNEAPOLIS MN
55406-2307
US

IV. Provider business mailing address

4323 E LAKE ST
MINNEAPOLIS MN
55406-2307
US

V. Phone/Fax

Practice location:
  • Phone: 612-722-1003
  • Fax: 612-721-6336
Mailing address:
  • Phone: 612-722-1003
  • Fax: 612-721-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP2754
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP2754
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP2754
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP2754
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberLP2754
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLP2754
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: