Healthcare Provider Details

I. General information

NPI: 1508273418
Provider Name (Legal Business Name): ROBERT HANSEN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 12TH AVE S
FARGO ND
58103-8753
US

IV. Provider business mailing address

2701 12TH AVE S
FARGO ND
58103-8753
US

V. Phone/Fax

Practice location:
  • Phone: 701-451-4900
  • Fax: 651-925-0057
Mailing address:
  • Phone: 701-451-4900
  • Fax: 651-925-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1736
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: