Basic Information
Provider Information | |||||||||
NPI: | 1740632421 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KISSICK | ||||||||
FirstName: | HANNAH | ||||||||
MiddleName: | NOEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW, RPT, PPSC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 855 N EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | ONTARIO | ||||||||
State: | CA | ||||||||
PostalCode: | 917622729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099832020 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 855 N EUCLID AVE | ||||||||
Address2: |   | ||||||||
City: | ONTARIO | ||||||||
State: | CA | ||||||||
PostalCode: | 91762 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099832020 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2016 | ||||||||
LastUpdateDate: | 01/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 72328 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 1041C0700X | CA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 87310 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.