MEDICARE: MICHELLE ANNE HANSEN DPT

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	225100000X	Physical Therapist	37325	CA

General Provider Information

NPI Number	:	1689976102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ANNE HANSEN DPT

Provider Business Mailing Address
First Line	:	1224 10TH ST STE 204
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-3420
Country	:	US
Telephone Number	:	619-437-6450
Fax Number	:	619-437-6672

Provider Business Practice Location Address
First Line	:	1224 10TH ST STE 204
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-3420
Country	:	US
Telephone Number	:	619-437-6450
Fax Number	:	619-437-6672

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

Provider Enumeration Date	:	12/04/2010
Last Update Date	:	06/13/2014

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