Provider Demographics
NPI:1104527118
Name:HANSEN, LIZAROSE Y T (CERTIFIED FAMILY HOM)
Entity type:Individual
Prefix:
First Name:LIZAROSE
Middle Name:Y T
Last Name:HANSEN
Suffix:
Gender:F
Credentials:CERTIFIED FAMILY HOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 MESQUITE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5135
Mailing Address - Country:US
Mailing Address - Phone:208-705-0591
Mailing Address - Fax:
Practice Address - Street 1:5201 MESQUITE DR APT 3
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5135
Practice Address - Country:US
Practice Address - Phone:208-705-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCFH-6547174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist