Provider Demographics
NPI:1043840788
Name:OUDEKERK, HANNAH MARIE
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:MARIE
Last Name:OUDEKERK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MADISON AVE.
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-8959
Mailing Address - Country:US
Mailing Address - Phone:507-682-7100
Mailing Address - Fax:
Practice Address - Street 1:306 MEADOW WOODS DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-8959
Practice Address - Country:US
Practice Address - Phone:507-995-9569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNK101150550102106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician