Healthcare Provider Details

I. General information

NPI: 1548736895
Provider Name (Legal Business Name): RONNIE HANSEN THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 MAIN ST. SUITE 107
PHILOMATH OR
97370
US

IV. Provider business mailing address

710 SW 57TH ST
CORVALLIS OR
97333-4480
US

V. Phone/Fax

Practice location:
  • Phone: 929-515-4102
  • Fax:
Mailing address:
  • Phone: 541-609-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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: RONNIE LOUISE HANSEN
Title or Position: OWNER
Credential: MSW, LCSW
Phone: 929-515-4102