Provider Demographics
NPI:1154381952
Name:HANSEN, AUDREY JO (ATC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JO
Last Name:HANSEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HORTON
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-5120
Mailing Address - Country:US
Mailing Address - Phone:309-438-5366
Mailing Address - Fax:309-438-5559
Practice Address - Street 1:205 HORTON
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-5120
Practice Address - Country:US
Practice Address - Phone:309-438-5366
Practice Address - Fax:309-438-5559
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096001752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer