Healthcare Provider Details

I. General information

NPI: 1972588473
Provider Name (Legal Business Name): MARK P HANSEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 ENERGY PARK DR SUITE 340
SAINT PAUL MN
55108-5276
US

IV. Provider business mailing address

1360 ENERGY PARK DR SUITE 340
SAINT PAUL MN
55108-5276
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-8985
  • Fax: 651-646-3959
Mailing address:
  • Phone: 651-646-8985
  • Fax: 651-646-3959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP 1440
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP 1440
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberLP 1440
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: