Provider Demographics
NPI:1841665528
Name:HANSON, DOREEN JOY
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:JOY
Last Name:HANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DOREEN
Other - Middle Name:JOY
Other - Last Name:BENCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19190 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7650
Mailing Address - Country:US
Mailing Address - Phone:320-305-1524
Mailing Address - Fax:
Practice Address - Street 1:19190 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-7650
Practice Address - Country:US
Practice Address - Phone:320-305-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1078276-1-HCBS385H00000X
MN1078862-1-AFC385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care