Provider Demographics
NPI:1861416760
Name:HANSEN, MARY CREER (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:CREER
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-4221
Mailing Address - Country:US
Mailing Address - Phone:303-980-8111
Mailing Address - Fax:303-722-0209
Practice Address - Street 1:777 S WADSWORTH BLVD
Practice Address - Street 2:4-170
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-4300
Practice Address - Country:US
Practice Address - Phone:303-980-8111
Practice Address - Fax:303-722-0209
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO471103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9612Medicaid
CO9612Medicaid