Provider Demographics
NPI:1871613125
Name:HANSEN, BRADIE ANN (MA)
Entity type:Individual
Prefix:MRS
First Name:BRADIE
Middle Name:ANN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 TRILLIUM LN
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-6405
Mailing Address - Country:US
Mailing Address - Phone:802-985-3603
Mailing Address - Fax:
Practice Address - Street 1:174 BATTERY ST STE 2
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-6201
Practice Address - Country:US
Practice Address - Phone:802-985-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2019-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047.0000712103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2232080OtherCIGNA BEHAVIORAL HEALTH
VT68032OtherBCBS OF VERMONT
VT1010473Medicaid