Basic Information
| Provider Information | |||||||||
| NPI: | 1942588421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANNON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 MORTHLAND DR STE A | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463854638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194629200 | ||||||||
| FaxNumber: | 2194651245 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 MORTHLAND DR STE A | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463854638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194629200 | ||||||||
| FaxNumber: | 2194651245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 87000841A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.