Provider Demographics
NPI:1447459037
Name:HANSEN, CRYSTAL (BSW, MHP)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:BSW, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-4151
Mailing Address - Country:US
Mailing Address - Phone:815-625-0013
Mailing Address - Fax:815-625-0197
Practice Address - Street 1:2611 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-4151
Practice Address - Country:US
Practice Address - Phone:815-625-0013
Practice Address - Fax:815-625-0197
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH52510680822104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker