Healthcare Provider Details

I. General information

NPI: 1750379111
Provider Name (Legal Business Name): HANNO W KIRK LICSW, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 W WASHINGTON ST
LEWISBURG WV
24901-1327
US

IV. Provider business mailing address

HC 40 BOX 41
LEWISBURG WV
24901-8811
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-3311
  • Fax:
Mailing address:
  • Phone: 304-647-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00036275
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: