Basic Information
| Provider Information | |||||||||
| NPI: | 1972588473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1360 ENERGY PARK DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516468985 | ||||||||
| FaxNumber: | 6516463959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 ENERGY PARK DR | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516468985 | ||||||||
| FaxNumber: | 6516463959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | LP 1440 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103T00000X | LP 1440 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | 103TP2701X | LP 1440 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
ID Information
| ID | Type | State | Issuer | Description | 42GI3HA | 01 | MN | BLUE CROSS& BLUE SHEILD | OTHER | 01009904 | 01 | MN | PREFERRED ONE | OTHER | 643353700 | 05 | MN | MEDICAID |