=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760099329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SPENCER REA HANSEN THOMAS LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2020
-----------------------------------------------------
Last Update Date | 09/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3340 LINEVILLE RD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54313-7237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-264-9564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3340 LINEVILLE RD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54313-7237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-264-9564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 7850-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------