Healthcare Provider Details

I. General information

NPI: 1104435064
Provider Name (Legal Business Name): HANNAH LORRAINE FANNON M.S., BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 MAPLEWOOD LN
WATERLOO IL
62298-2797
US

IV. Provider business mailing address

1120 MAPLEWOOD LN
WATERLOO IL
62298-2797
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-8332
  • Fax: 618-719-3410
Mailing address:
  • Phone: 618-719-3410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number95001569A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1215462
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: