Basic Information
| Provider Information | |||||||||
| NPI: | 1912304734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSET | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10564 SE WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033347620 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Practice Location | |||||||||
| Address1: | 10564 SE WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033347620 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2014 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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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 | 175T00000X | 175T00000X - PEER | OR | N | 324500000X | 12-CRM-070 | OR | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 175T00000X | 01 | OR | : 175T00000X PEER SPECIALIST | OTHER |