Basic Information
| Provider Information | |||||||||
| NPI: | 1700987658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANEY | ||||||||
| FirstName: | SELENA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 FINDLAY ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063298588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4578 GALLIA PIKE | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN FURNACE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403510008 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | QMHS | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | CMS | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | LCDCII.161634 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0365668 | 05 | OH | MEDICAID | 30610026 | 05 | KY | MEDICAID |