Healthcare Provider Details

I. General information

NPI: 1396084901
Provider Name (Legal Business Name): SHELLEY K HANSEN, LSW, MA, LP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 EAST FOURTH STREET SUITE 302
NORTHFIELD MN
55057-2050
US

IV. Provider business mailing address

105 EAST FOURTH STREET SUITE 302
NORTHFIELD MN
55057-2050
US

V. Phone/Fax

Practice location:
  • Phone: 612-532-6741
  • Fax:
Mailing address:
  • Phone: 612-532-6741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3954
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW5063
License Number StateMN

VIII. Authorized Official

Name: SHELLEY KAY HANSEN
Title or Position: OWNER
Credential: LSW,MA, LP
Phone: 612-532-6741