=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154139236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE DENISE HANSON-SIAS MA, LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 TYLER ST NE STE 170
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55413-1580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-259-7384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53495 EMERALD AVE
-----------------------------------------------------
City | RUSH CITY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55069-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-224-9978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CC04657
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------