Healthcare Provider Details

I. General information

NPI: 1114375045
Provider Name (Legal Business Name): MOLLIE HANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 TIETON DR STE C
YAKIMA WA
98908
US

IV. Provider business mailing address

5301 TIETON DR STE C
YAKIMA WA
98908-3479
US

V. Phone/Fax

Practice location:
  • Phone: 509-965-7100
  • Fax: 509-966-9750
Mailing address:
  • Phone: 509-965-7100
  • Fax: 509-966-9750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberG60655200
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberAB60925122
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: