Basic Information
| Provider Information | |||||||||
| NPI: | 1811103492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 27 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067952601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602744092 | ||||||||
| FaxNumber: | 8602744099 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 DALE RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606741713 | ||||||||
| FaxNumber: | 8606741848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 008026 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9508 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080008026CT01 | 01 | CT | ANTHEM BCBS | OTHER |