Provider Demographics
NPI:1104319110
Name:HANSON, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:HANSON
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 1:18716 GARDNER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-8214
Mailing Address - Country:US
Mailing Address - Phone:541-226-1386
Mailing Address - Fax:
Practice Address - Street 1:210 COVE RD
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-2520
Practice Address - Country:US
Practice Address - Phone:541-469-0222
Practice Address - Fax:541-469-0228
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR680503Medicaid