Healthcare Provider Details

I. General information

NPI: 1619241205
Provider Name (Legal Business Name): VIVIAN R HANSEN BS,CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24823 PACIFIC HWY S
KENT WA
98032-5478
US

IV. Provider business mailing address

24823 PACIFIC HWY S
KENT WA
98032-5478
US

V. Phone/Fax

Practice location:
  • Phone: 253-681-0010
  • Fax: 253-681-0014
Mailing address:
  • Phone: 253-681-0010
  • Fax: 253-681-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00000011
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: