Basic Information
| Provider Information | |||||||||
| NPI: | 1174898647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | KIMBALL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 E 10TH AVE STE 178 | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014088500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2012 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 10801683-1205 | UT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.