Basic Information
| Provider Information | |||||||||
| NPI: | 1023523230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 12TH AVE W STE 1 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187492877 | ||||||||
| FaxNumber: | 2187496033 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S 12TH AVE W STE 1 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187492877 | ||||||||
| FaxNumber: | 2187496033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2017 | ||||||||
| LastUpdateDate: | 12/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 303986 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1619984028 | 05 | MN | MEDICAID |