Healthcare Provider Details

I. General information

NPI: 1518612605
Provider Name (Legal Business Name): LIA MARCELETTE HANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 CATHY LN STE 103
BURLINGTON NJ
08016-9727
US

IV. Provider business mailing address

4182 HARBOUR DR
PALMYRA NJ
08065-2108
US

V. Phone/Fax

Practice location:
  • Phone: 609-499-0165
  • Fax: 609-499-0685
Mailing address:
  • Phone: 609-634-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00503000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: