Provider Demographics
NPI:1154869519
Name:HANSEN, IAN (MA LMFT #121960)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MA LMFT #121960
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3505
Mailing Address - Country:US
Mailing Address - Phone:909-599-1227
Mailing Address - Fax:909-670-1596
Practice Address - Street 1:762 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3505
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:909-670-1596
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99567106H00000X
390200000X
CA121960106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program