Basic Information
| Provider Information | |||||||||
| NPI: | 1881253060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | KOURTNEY | ||||||||
| MiddleName: | BAILEY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1529 E PALMDALE BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935502029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612729996 | ||||||||
| FaxNumber: | 6612242187 | ||||||||
| Practice Location | |||||||||
| Address1: | 1529 E PALMDALE BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935502029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612729996 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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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 | 101YM0800X | AMFT78253 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.