Healthcare Provider Details

I. General information

NPI: 1942588421
Provider Name (Legal Business Name): PAUL R HANNON LCAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 MORTHLAND DR STE A
VALPARAISO IN
46385-4638
US

IV. Provider business mailing address

660 MORTHLAND DR STE A
VALPARAISO IN
46385-4638
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-9200
  • Fax: 219-465-1245
Mailing address:
  • Phone: 219-462-9200
  • Fax: 219-465-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87000841A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: