Healthcare Provider Details

I. General information

NPI: 1770359804
Provider Name (Legal Business Name): DESTINY LYNN HANNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W MAIN ST
KELSO WA
98626-1118
US

IV. Provider business mailing address

1302 COMMERCE AVE
LONGVIEW WA
98632-3096
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-2806
  • Fax:
Mailing address:
  • Phone: 360-423-2806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number61636878
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: