Healthcare Provider Details

I. General information

NPI: 1477868602
Provider Name (Legal Business Name): BRIAN HANSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 N. MAIN STREET
LEEDS UT
84746-0993
US

IV. Provider business mailing address

PO BOX 460993 480 N. MAIN STREET
LEEDS UT
84746-0993
US

V. Phone/Fax

Practice location:
  • Phone: 435-879-6990
  • Fax:
Mailing address:
  • Phone: 435-879-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number140877-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: