Provider Demographics
NPI:1437195641
Name:HANISCH THEISEN, CHARLENE MARIE (MS LICSW)
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:MARIE
Last Name:HANISCH THEISEN
Suffix:
Gender:F
Credentials:MS LICSW
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:MARIE
Other - Last Name:CARROLL HANISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS LICSW
Mailing Address - Street 1:720 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4498
Mailing Address - Country:US
Mailing Address - Phone:320-308-3171
Mailing Address - Fax:320-308-0959
Practice Address - Street 1:850 1ST AVE SOUTH
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4498
Practice Address - Country:US
Practice Address - Phone:320-308-3171
Practice Address - Fax:320-308-0959
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12147104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
49F67CAOtherBCBS
MN796113800Medicaid
6256246OtherMEDICA
922241027913OtherPREFERRED ONE
HP33738OtherHEALTH PARTNERS
151607C851OtherUCARE