Provider Demographics
NPI:1447347711
Name:HANSON, WAVERLY JULE (LPC)
Entity type:Individual
Prefix:
First Name:WAVERLY
Middle Name:JULE
Last Name:HANSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:WAVERLY
Other - Middle Name:JULE
Other - Last Name:TYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:580 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8512
Mailing Address - Country:US
Mailing Address - Phone:719-661-7330
Mailing Address - Fax:719-265-1921
Practice Address - Street 1:5085 LIST DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3345
Practice Address - Country:US
Practice Address - Phone:719-661-7330
Practice Address - Fax:719-265-1921
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2492101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
22703OtherNATIONAL CERTIFIED COUNSE
CO2492OtherLICENSE