Provider Demographics
NPI:1124450234
Name:HANSEN, ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:COREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:86 SAXON AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7018
Mailing Address - Country:US
Mailing Address - Phone:631-807-8483
Mailing Address - Fax:
Practice Address - Street 1:86 SAXON AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7018
Practice Address - Country:US
Practice Address - Phone:631-807-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY1288831103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool