Provider Demographics
NPI:1528294352
Name:HANSEN, KATIE ANN
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ANN
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 1:305 S REGENCY DR
Mailing Address - Street 2:#1
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4343
Mailing Address - Country:US
Mailing Address - Phone:309-224-7560
Mailing Address - Fax:
Practice Address - Street 1:305 S REGENCY DR
Practice Address - Street 2:#1
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4343
Practice Address - Country:US
Practice Address - Phone:309-224-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist