MEDICARE: HALLEJO MARINA HANSON

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	106S00000X	Behavior Technician	RBT-25-468106

General Provider Information

NPI Number	:	1619819984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALLEJO MARINA HANSON

Provider Business Mailing Address
First Line	:	4721 S CLIFF AVE STE 103
Second Line	:
City	:	INDEPENDENCE
State	:	MO
Zip	:	64055-6969
Country	:	US
Telephone Number	:	816-608-1500
Fax Number	:	800-687-5070

Provider Business Practice Location Address
First Line	:	12100 SAINT CHARLES ROCK RD UNIT 5
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2601
Country	:	US
Telephone Number	:	636-398-2500
Fax Number	:	800-687-5070

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

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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Directions to “ HALLEJO MARINA HANSON ” Practice Location

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