Basic Information
| Provider Information | |||||||||
| NPI: | 1689823122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5003 S MIAMI BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277038589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193540840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2076 NC HIGHWAY 42 W STE 220 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195503323 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.