Provider Demographics
NPI:1548363161
Name:HANSON, AMY S (LPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:HANSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-2870
Mailing Address - Country:US
Mailing Address - Phone:314-667-9410
Mailing Address - Fax:
Practice Address - Street 1:1048 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-2870
Practice Address - Country:US
Practice Address - Phone:314-667-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20022020527101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495955700Medicaid