Provider Demographics
NPI:1780579268
Name:HANSON, CHARLIE
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:HANSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 SE CESAR E CHAVEZ BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5260
Mailing Address - Country:US
Mailing Address - Phone:650-619-5106
Mailing Address - Fax:
Practice Address - Street 1:1730 SW SKYLINE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2547
Practice Address - Country:US
Practice Address - Phone:971-203-2326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty