Healthcare Provider Details

I. General information

NPI: 1184897563
Provider Name (Legal Business Name): MR. KEVIN HANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 NIAGARA STREET ADOLESCENT PROGRAM
BUFFALO NY
14213
US

IV. Provider business mailing address

254 FRANKLIN STREET LAKE SHORE BEHAVIORAL HEALTH, INC
BUFFALO NY
14202
US

V. Phone/Fax

Practice location:
  • Phone: 716-818-7195
  • Fax: 716-884-1758
Mailing address:
  • Phone: 716-842-0440
  • Fax: 716-842-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: