MEDICARE: SANDRA M. HANSEN MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC 34472	CA

General Provider Information

NPI Number	:	1205045861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA M. HANSEN MFT

Provider Business Mailing Address
First Line	:	2655 PORTAGE BAY E
Second Line	:	SUITE 10
City	:	DAVIS
State	:	CA
Zip	:	95616-3073
Country	:	US
Telephone Number	:	530-758-1282
Fax Number	:

Provider Business Practice Location Address
First Line	:	2655 PORTAGE BAY E
Second Line	:	SUITE 10
City	:	DAVIS
State	:	CA
Zip	:	95616-3073
Country	:	US
Telephone Number	:	530-758-1282
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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