Provider Demographics
NPI:1386172005
Name:HANSEN, MELANIE ANN FAUSTINO
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN FAUSTINO
Last Name:HANSEN
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 1:510 W 2965 S
Mailing Address - Street 2:
Mailing Address - City:NIBLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6301
Mailing Address - Country:US
Mailing Address - Phone:480-313-9180
Mailing Address - Fax:
Practice Address - Street 1:2150 N MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1740
Practice Address - Country:US
Practice Address - Phone:435-932-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10374737-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist