Basic Information
| Provider Information | |||||||||
| NPI: | 1184897563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | KEVIN | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 FRANKLIN STREET | ||||||||
| Address2: | LAKE SHORE BEHAVIORAL HEALTH, INC | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 NIAGARA STREET | ||||||||
| Address2: | ADOLESCENT PROGRAM | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168187195 | ||||||||
| FaxNumber: | 7168841758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.