MEDICARE: MR. GARY D HANSON LMFT

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	1241	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1241	OTHER	MN	LMFT LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	107643	OTHER	MN	HEALTH PART ID NUMBER
4	62-90571	OTHER	MN	MEDICA ID NUMBER
5	337M8HA	OTHER	MN	BCBS MN PROVIDER ID

General Provider Information

NPI Number	:	1215927066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY D HANSON LMFT

Provider Business Mailing Address
First Line	:	7200 HEMLOCK LN N SUITE 108
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-5576
Country	:	US
Telephone Number	:	763-533-5339
Fax Number	:	763-390-0863

Provider Business Practice Location Address
First Line	:	7200 HEMLOCK LN N SUITE 108
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-5576
Country	:	US
Telephone Number	:	763-533-5339
Fax Number	:	763-390-0862

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	10/27/2014

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